181

Chapter 5 

E-Cigarette Policy and Practice Implications

Introduction 183

Critical Issues Related to Policies on E-Cigarettes in 2016 184

The E-Cigarette Landscape Is Dynamic and Evolving 184

Risk Tradeoffs Are Inherent for E-Cigarettes 184

Additional Evidence Suggested for Future Research 185

Potential Public Policy Approaches 187

Clean Indoor Air Policies 188

Prevent Youth Access 203

Licensing 203

Taxation and Other Price Policies 204

Restrictions on Marketing 205

Educational Initiatives 206

Implications for Health Care Practice 206

Case Studies 224

Summary and Recommendations 225

Conclusions 226

References 227

E-Cigarette Policy and Practice Implications 183

E-Cigarette Use Among Youth and Young Adults

Introduction

The previous chapters have set out what is currently 

known and not known about e-cigarettes. Despite the 

identified gaps in evidence and the dynamic, evolving patterns of the use of e-cigarettes, policy options are needed. 

These policy options are particularly important as they 

affect the use of e-cigarettes by youth and young adults. 

As this report has demonstrated, e-cigarettes are widely 

used by youth and young adults and are particularly risky 

for these age groups, and efforts to prevent their use by 

young people are needed. This chapter explores the policy 

landscape of e-cigarettes and sets forth recommendations 

that should protect the public’s health, particularly as 

these policies relate to the short- and long-term health of 

youth and young adults.

The Family Smoking Prevention and Tobacco 

Control Act of 2009 (or Tobacco Control Act) (2009) is 

meant to protect the health of the public, including young 

people. As previously discussed, on May 10, 2016, FDA 

published a final rule which deemed all other products, 

including e-cigarettes, meeting the definition of a tobacco 

product, except accessories of such products, to be subject to the Federal Food, Drug, and Cosmetic Act. This 

rule went into effect on August 8, 2016 (Federal Register 

2016). Under the Tobacco Control Act, FDA likely will be 

required to consider the consequences of e-cigarette use 

for those who do not use tobacco products (as well as for 

those who do).

It can be stated that public health will be harmed if

the availability of e-cigarettes:

• Increases exposure to nicotine among youth and 

young adults;

• Leads to the initiation of combustible tobacco 

smoking;

• Slows or prevents cessation of combustible products 

by nicotine-addicted smokers; or

• Increases the likelihood that former smokers will 

again become addicted to nicotine and/or use combustible products after being reintroduced to nicotine by e-cigarettes.

Potential harm also comes from secondhand exposure to the vapor or aerosol expelled from e-cigarette 

users. Secondhand exposure comes from inhaling the 

aerosol or contacting vapor-contaminated surfaces. Each 

of the potential negative consequences of the availability 

of e-cigarettes could lead to additional disease and premature mortality (Chapter 3).

Relative to efforts in cigarette and smokeless tobacco 

use prevention and control, a polarized debate has been in 

progress for several years over the role of e-cigarettes. There 

is general agreement that exclusive use of e-cigarettes poses 

a lower health risk to the individual than the extremely high 

health risks of using conventional, combustible tobacco 

products (Farsalinos and Polosa 2014; Grana et al. 2014a,b), 

although more research is needed on this as more becomes 

known about the harmful constituents of e-cigarettes 

(Sleiman et al. 2016). The controversy reflects the relative 

degree of emphasis given to the potential harm to adolescents and young adults from using e-cigarettes at one pole 

compared with the potential for reduced risk for established adult users of conventional cigarettes at the other (if 

they transition completely to e-cigarettes). Although this 

characterization does not reflect the complexity of the situation, it is useful in defining the potential tradeoffs that 

are implicit: increased numbers of young people who are 

exposed to nicotine (and who may go on to conventional 

tobacco products) versus reduced health risks to individuals who completely switch from conventional, combustible tobacco products with their extremely high health 

risks. The discussion has become increasingly complicated 

as e-cigarette use has increased, and still-incomplete evidence potentially supports the views of those holding to 

both poles of the argument about reducing harm for the 

overall population. However, the majority of currently 

available scientific evidence does not support the recommendation to use e-cigarettes for the cessation of cigarette smoking (Hartmann-Boyce et al. 2016). Additionally, 

the use of e-cigarettes does not pose benefits to youth and 

young adults, and some data suggest that use of e-cigarettes 

could lead to the more harmful use of conventional cigarettes. In the context of young people, the precautionary 

principle should apply. The precautionary principle is 

defined by the United Nations Educational, Scientific and 

Cultural Organization (2005) as appropriate “when human 

activities may lead to morally unacceptable harm that is scientifically plausible but uncertain, actions shall be taken to 

avoid or diminish that harm” (p.14).
A Report of the Surgeon General

184 Chapter 5

Critical Issues Related to Policies on E-Cigarettes in 2016

The E-Cigarette Landscape Is 

Dynamic and Evolving

Considerations of policy approaches to e-cigarettes 

offered in this report are made in the context of a rapidly changing marketplace for nicotine-containing products that now includes primarily conventional cigarettes, cigars, smokeless products, hookahs, and 

e-cigarettes (see Chapter 2). The manufacture and sales 

of nicotine-containing products, once dominated by a few 

large companies selling conventional cigarettes, have been 

transformed and now include many smaller companies 

that manufacture and sell through stores and “vape shops.” 

E-cigarettes are also sold through websites and in places 

where conventional cigarettes have long been available—

convenience stores, pharmacies, gas stations, and grocery 

stores. Currently, hundreds of different e-cigarette products 

are on the market: designs are evolving rapidly, and major 

tobacco companies have their own lines of e-cigarette products. However, unlike the situation in the past in which the 

marketing of conventional tobacco products changed relatively slowly and there were limited media outlets, information about e-cigarettes is now promoted quickly through 

new media, as well as television, in part to reach key target 

groups, including youth and young adults.

As documented in Chapter 2, patterns of use are rapidly changing among adolescents and young adults, and 

likely among other groups within the population. For some 

of the most critical issues related to e-cigarettes, longitudinal data are not yet available because the use of these 

products is recent and constantly changing, and whether 

and when the patterns of use will stabilize is uncertain. 

Additionally, surveillance data and research on the wideranging consequences of e-cigarette use, including such 

key issues as the likelihood of addiction and other health 

problems for users and those passively exposed, are lagging behind the highly dynamic changes in the nicotineproduct marketplace and the impact of these changes on 

the use of tobacco products, including e-cigarettes.

 With regard to the potential health consequences of 

using e-cigarettes, estimates can be made based on knowledge of the characteristics and components of the aerosols 

that are then inhaled. Unfortunately, evidence on shortterm risks is limited, and long-term risks have not yet been 

identified because this would require monitoring users for 

years. For example, the impact of long-term inhalation of 

flavorings is not yet known. While some of the flavorings 

used in e-cigarettes are generally recognized as safe for 

ingestion as food, the health effects of their inhalation are 

generally unknown, and some flavorings have been shown 

to cause a serious lung disease, bronchiolitis obliterans, 

when inhaled (Kreiss et al. 2002; Barrington-Trimis et al. 

2014). Whether the risk of lung disease or other disorders 

is truly substantial will require longer term epidemiologic 

and other research (Allen et al. 2016).

Thus, policy approaches must support control measures that (a) are as dynamic as the rapidly changing marketplace for e-cigarettes; (b) are supported by surveillance 

data; and (c) document in timely fashion the current status 

of the use of multiple types of tobacco products (including 

e-cigarettes); the emergence of state, local, tribal, and territorial policies; and the strategies being used to market these 

products.

Risk Tradeoffs Are Inherent for 

E-Cigarettes

Policy discussions about e-cigarettes have highlighted 

the potential tradeoffs in risk that could occur, particularly 

if e-cigarettes are positioned as a harm-reducing alternative to combustible tobacco products. Some have characterized these products as new technologies that might lead 

to a dramatic decline in the use of more dangerous forms 

of nicotine delivery, particularly conventional cigarettes 

and other combustible tobacco products (Abrams 2014; 

Cobb and Abrams 2014; Fagerström and Bridgman 2014; 

Grana et al. 2014a; Hajek et al. 2014; Henningfield 2014; 

Schraufnagel et al. 2014; West and Brown 2014; Lindblom 

2015). Correspondingly, e-cigarettes have been proposed by 

some as a harm-reduction strategy and as a tool for smoking 

cessation, but the data to date do not support e-cigarettes 

for harm reduction or cessation (Siegel et al. 2011; Abrams 

2014). By contrast, others are concerned that the availability of these new products will expand the number of 

youth and young adults who are exposed to nicotine and 

will eventually lead to exclusive use of other conventional 

tobacco products or dual use of both (e-cigarettes and conventional cigarettes) (Leventhal et al. 2015; Primack et al. 

2015). Early longitudinal evidence provides some support 

for these concerns, although further research on this issue 

is still warranted.

As reviewed in Chapter 3, uncertainty remains 

about the health effects of e-cigarettes, particularly in the 

long term. Such effects will remain unknown until sufficient observations can be made over time. However, current knowledge of the characteristics of the inhaled aerosol 

from e-cigarettes suggests that if a current adult smoker of 
E-Cigarette Policy and Practice Implications 185

E-Cigarette Use Among Youth and Young Adults

conventional cigarettes or other combustible tobacco products would use e-cigarettes exclusively instead of combustibles as a substitute nicotine delivery system, either en route 

to quitting tobacco completely or even as a long-term 

alternative, the risks of tobacco-related diseases would be 

reduced substantially compared with the risk imparted by 

continued smoking of conventional cigarettes (Fiore et al. 

2014; USDHHS 2014; McNeill et al. 2015).

Still, as documented in Chapter 3, immediate and 

future health risks for youth and young adults who use 

e-cigarettes can be anticipated from exposure to nicotine, 

including addiction and harmful effects on brain development. Research must continue to characterize and quantify the full spectrum of potential health risks. Thus, in 

formulating policies related to the role of e-cigarettes 

in tobacco control and reducing the burden of tobaccorelated disease, particularly among youth and young 

adults, e-cigarette products that deliver nicotine cannot 

be considered a risk-free alternative to conventional cigarettes or other combustible tobacco products.

Any analysis of the potential increased risks and 

reduced harms of e-cigarette use also needs to consider 

data on the actual patterns of use because more of the 

risks affect youth and young adults and most of the potential benefits from reduced risk to health largely accrue 

to older cigarette smokers (Chapter 2). However, the 

reports of the tobacco industry to investors indicate the 

industry’s interest in maintaining a broad pattern of use 

of nicotine-containing products, including conventional 

cigarettes, for decades to come (Calantzopoulos 2015). 

When considered in the context of the tobacco industry’s 

past changes to product design (e.g., the creation of socalled “low-tar” cigarettes), the broader array of tobacco 

products now being discussed within the tobacco industry’s plans (e.g.,  “Heat-Not-Burn” products) could slow 

cessation (because smokers have historically been drawn 

to reduced-harm products) and thus the overall decline of 

tobacco-related diseases (USDHHS 2014).

The dynamic balancing between risks and potential 

benefits of e-cigarette use will be swayed by the impact of 

such use on the use of other tobacco products by youth 

and young adults over time. The availability of e-cigarettes 

could adversely affect the use of tobacco products in 

this group by slowing the decline of smoking because 

this population will be exposed to nicotine and possibly 

become addicted to that substance. Indeed, data reviewed 

in Chapter 2 show evidence of such trends. Although 

the decline in rates of smoking conventional cigarettes 

and other combustible tobacco products is viewed universally as positive, the increasing number of youth and 

young adults who use e-cigarettes is a serious concern for 

all the reasons cited above. West and Brown (2014) and 

McNeill and colleagues (2015) suggest that the limited 

evidence from the United Kingdom does not support the 

concern that using e-cigarettes leads to the use of other 

tobacco products, and they maintain that the new adolescent users of these e-cigarette products include very few 

never smokers. However, the marketing of e-cigarettes is 

quite different between the United Kingom and the United 

States, and the patterns of use, particularly among youth, 

are also quite different (European Parliament and Council 

2014; England et al. 2015; Klein 2015; Leventhal et al. 

2015; Primack et al. 2015; Barrington-Trimis et al. 2016; 

Wills et at. 2016; Institute for Global Tobacco Control 

n.d.). This pattern is also evident in some U.S. survey 

data from early in the era of e-cigarette use (as reviewed 

in Chapter 2), but not in more recent data, which indicate that e-cigarette products may contribute to nicotine 

addiction in a new generation of young people and thereby 

lead to increased use of a variety of nicotine delivery products, including combustible tobacco (Bauld et al. 2016; 

CDC 2016).

Fundamentally, the public health challenge and the 

charge to policy development can be framed as balancing 

the potential use of e-cigarettes as a new technology to 

reduce the use of combustible tobacco products against 

the possibility of expanding tobacco use among non-using 

youth and young adults, long-term former smokers, and 

other vulnerable populations (e.g., women of reproductive age and individuals with significant comorbidities, 

including those with mental health problems). Already, the 

e-cigarette companies are increasing the appeal of their 

offerings by enhancing the efficiency of nicotine delivery 

and using flavorings while they continue to advertise and 

promote their products aggressively.

Additional Evidence Suggested for 

Future Research

To characterize the critical balance for public health 

between the harms and potential benefits of e-cigarettes, 

more evidence on each of the elements that determine 

that balance would be useful (Table 5.1). The needed 

data would come from surveillance of patterns of adoption of e-cigarettes and their use among the population generally, and particularly among the most critical 

populations for uptake: youth and young adults, former 

smokers, smokers, and other populations that are particularly at risk for adverse outcomes. Few studies have been 

done on the health risks posed by e-cigarettes and their 

potential effectiveness for smoking cessation (HartmannBoyce et al. 2016). However, as discussed in Chapter 2, 

there are still no standardized questions for research on 
A Report of the Surgeon General

186 Chapter 5

e-cigarettes, and there is a need for further testing and 

development of e-cigarette questions and measurements.

Table 5.1 Comparative risk assessment: Potential harms and benefits of e-cigarettes

Harms Benefits

Increased youth exposure to nicotine and potentially greater 

initiation of conventional cigarettes

Reduced disease risk for current smokers who completely switch 

to e-cigarettes 

Slowing cessation by smokers due to nicotine addiction Reduced disease morbidity for smokers with existing heart or 

lung disease who switch to e-cigarettes 

Nicotine addiction in former smokers who begin to use 

e-cigarettes and possibly transition back to smoking

Potential for cessation of combustible products

Renormalization of nicotine use and smoking as acceptable Fewer users of combustible products in the entire population

Future disease risks for youth who are exposed to nicotine

Increasing the dual use of e-cigarettes with combustible 

products 

Serving as a “gateway” to the initiation of tobacco smoking 

Increased disease risk vs. complete cessation among those who 

use both e-cigarettes and combustible products

Exposure to secondhand aerosol and lack of clean air

To characterize the harms and benefits of e-cigarettes 

to public health, models are used to project their overall 

impact on public health (Levy et al. 2016). The use of modeling was described in detail in the 2014 Surgeon General’s 

report (USDHHS 2014). Conceptual models are needed to 

define the potential scenarios of changes in patterns of use 

among youth, young adults, adult smokers, former smokers, 

and other significant vulnerable populations. Figure 5.1 displays the range of patterns that are emerging with the wider 

adoption of e-cigarettes (Cobb et al. 2015; Vugrin et al. 2015). 

Researchers and public health officials can use dynamic 

population models (Mejia et al. 2010; Kalkhoran and Glantz 

2015; Vugrin et al. 2015; Levy et al. 2016) to analyze the 

potential impact on population health of the relative probabilities of these various paths. Initial modeling has shown 

that the potential population health benefits are very sensitive to several factors: the levels of product risk, particularly 

those of e-cigarettes; patterns of initiation and switching; and 

the extent of dual use (Mejia et al. 2010; Cobb et al. 2015; 

Kalkhoran and Glantz 2015; Vugrin et al. 2015). The benefits of smoking cessation, particularly as early in life as possible, are well documented, but the epidemiologic evidence 

that reducing (but not quitting) cigarette consumption can 

lower the risk of all-cause mortality, or mortality from cardiovascular diseases, remains inconclusive (USDHHS 2014). 

Thus, more research is needed to better characterize the 

health consequences of dual use, in particular, in comparison to the recognized health benefits of complete smoking 

cessation (or potentially only e-cigarette use). Similarly, the 

health risks to former smokers who become exposed again 

to nicotine through e-cigarettes are uncertain. Data are still 

limited on the risk of starting (or not starting) to smoke conventional cigarettes again (after successful cessation) following exposure to nicotine via e-cigarettes.

As reviewed in Chapter 3, the long-term health risks 

of e-cigarettes will not be known for decades, although evidence to date suggests that they are generally less harmful 

than combustible products. However, less harmful is not 

the same as harmless. A substantial amount of evidence 

is available on some components of the aerosols inhaled 

by e-cigarette users. For many people, exposure to aerosol 

could occur across much of the life span, beginning in 

adolescence and even in childhood, when the lungs and 

brain are still developing. Flavorings are of particular concern with regard to pulmonary toxicity, as are the various 

effects of nicotine on the brain. Although the National 

Institutes of Health is now supporting a growing program 

of research on e-cigarettes, critical questions have not yet 

been answered. Given experiences with conventional cigarettes, long-term studies will be needed to identify the full 

health consequences of using e-cigarettes.

Thus, policies related to e-cigarettes will necessarily 

be made in the context of accumulating but incomplete 

evidence. The landscape is changing rapidly and, inevitably, research cannot keep pace. Quoting Sir Austin 

Bradford Hill’s landmark paper on environment and disease: “All scientific work is incomplete—whether it be 

observational or experimental. All scientific work is liable 

to be upset or modified by advancing knowledge. That 

does not confer on us a freedom to ignore the knowledge 

we already have, or to postpone the action that it appears 

to demand at a given time” (Hill 1965, p. 300).
E-Cigarette Policy and Practice Implications 187

E-Cigarette Use Among Youth and Young Adults

Figure 5.1 Potential patterns of use of combustible products (CPs) and e-cigarettes (e-cigs)

Source: USDHHS (2014). Adapted for this report.

Potential Public Policy Approaches

In formulating public policies related to e-cigarettes, 

the context and possibilities vary across the national, 

state, local, tribal, and territorial governments and public 

entities. At the national level, progressive steps are being 

taken by FDA under the Tobacco Control Act. In 2010, 

the U.S. Court of Appeals for the D.C. Circuit determined 

that e-cigarettes and other products made or derived from 

tobacco may be regulated by FDA as tobacco products 

under the Tobacco Control Act and are not drugs or devices 

unless marketed for therapeutic purposes, such as being 

an aid to smoking cessation (Sottera, Inc. v. Food and 

Drug Administration 2010). In May 2016, FDA released 

its deeming rule to regulate the sale and distribution of 

e-cigarettes as a tobacco product (see Chapter 1) (Federal 

Register 2016). The rule is currently under litigation. The 

rule restricts the age of sale to those 18 years of age and 

older and requires retailers to check the age identification 

of young people under age 27, restricts vending machines 

to adult-only facilities, prohibits free samples, requires a 

health-warning statement about nicotine on packaging 

and in advertisements, requires domestic manufacturers 

to register their products and disclose the ingredients 

of their products, requires the reporting of the levels of 

harmful and potentially harmful constituents to FDA, 

allows FDA to review any new or changed products before 

being sold, and requires manufacturers to show scientific 

evidence that demonstrates the overall public health benefit of any product before it can be marketed as a modified 

risk tobacco product (Federal Register 2016). The Tobacco 

Control Act does not provide FDA with authority to impose 

taxes on tobacco products (Bhatnagar et al. 2014; Huang 

et al. 2014; Tobacco Control Legal Consortium 2015) or 
A Report of the Surgeon General

188 Chapter 5

regulate indoor air quality (Schripp et al. 2013; Bam et al. 

2014; Bhatnagar et al. 2014; Brandon et al. 2015a), occupational health and safety (USDHHS 2015; Whitsel et al. 

2015), or hazardous waste disposal (Chang 2014; Krause 

and Townsend 2015).

FDA is not the only federal agency with potential 

jurisdiction over some aspect of e-cigarettes (Table 5.2). 

For example, the U.S. Department of Defense and U.S. 

Department of Veterans Affairs relate to specific populations, and other agencies relate to regulatory activities, such 

as the U.S. Federal Trade Commission, U.S. Department 

of Transportation, and the U.S. Environmental Protection 

Agency. Some agencies have coverage over specific areas, 

such as the General Services Administration and the 

National Park Service.

State, local, tribal, and territorial governments, as well 

as private entities, may also address these and other matters that are covered by the Tobacco Control Act (Freiberg 

2012), and since 2010 many actions have been taken at 

the nonfederal level. State and local governments may utilize effective interventions that would also be expected to 

apply to e-cigarettes: increasing the price of tobacco products through taxation (Community Preventive Services 

Task Force 2012); creating and enforcing clean air policies 

(Hopkins et al. 2010); and passing comprehensive laws prohibiting sales to minors, combined with active enforcement 

(Community Preventive Services Task Force 2001). In addition, based on evidence that new e-cigarette products may 

addict a generation of young people to nicotine (Bunnell 

et al. 2015; CDC 2015b) and on mounting indications about 

potential harm from the use of these products in this population (Flouris et al. 2013; Barrington-Trimis et al. 2014; 

Goniewicz et  al. 2014; Grana et al. 2014a; Pisinger and 

Dossing 2014; Goniewicz and Lee 2015), numerous health 

organizations have called for the extension of smokingrelated policies to e-cigarettes (Association of State and 

Territorial Health Officials 2014; Bam et al. 2014; Bhatnagar 

et al. 2014; Offermann 2014; Schraufnagel et al. 2014; World 

Health Organization 2014a; Brandon et al. 2015a; USDHHS 

2015). In the absence of causal findings that have guided 

evidence-based tobacco control for decades, the “precautionary principle” is relevant to decision makers as a guide 

to action to address e-cigarettes among youth and young 

adults. This principle supports intervention to avoid possible health risks when the potential risks remain uncertain 

and have been as yet partially undefined (Bialous and Sarma 

2014; Saitta et al. 2014; Hagopian et al. 2015). However, the 

interventions should be appropriate to the currently perceived risk for future health consequences, in this case 

from e-cigarette use by youth, young adults, and pregnant 

women, as well as from the secondhand exposure of nonusers to e-cigarette vapor.

Clean Indoor Air Policies

Clean indoor air or smokefree policies prohibit 

the use of conventional tobacco products in indoor 

public places, such as worksites, restaurants, bars, and 

casinos. Because most of these policies predate the rise 

of e-cigarettes, their language does not necessarily 

cover emissions from these products. To protect the 

public from both secondhand smoke and secondhand 

aerosol, smokefree air policies should be modernized 

to include e-cigarettes. Such policies will maintain current standards for clean indoor air, reduce the potential 

for renormalization of tobacco product use, and prevent 

involuntary exposure to nicotine and other aerosolized 

emissions from e-cigarettes (Ingebrethsen et al. 2012; 

Schripp et al. 2013; Goniewicz et al. 2014; Offermann 

2014; Schober et al. 2014). Updating existing policies to 

cover e-cigarettes (and all electronic nicotine delivery systems) will eliminate the introduction of airborne toxins 

into enclosed spaces and establish a uniform standard for 

preventing the use of both combustible and electronic 

tobacco products in public and private spaces, including 

schools, offices, restaurants, bars, casinos, and airplanes.

Prohibiting the use of e-cigarettes in enclosed 

spaces eliminates potential health risks to nonusers and 

ensures their right to clean air; may discourage the dual 

use of electronic and combustible tobacco products; simplifies public compliance with and enforcement of existing 

clean indoor air laws; facilitates reduced consumption of 

these products; and maintains clear, comprehensive nonsmoking norms (Richardson et al. 2014; World Health 

Organization 2014a). As of January 1, 2016, six states 

(Delaware, Hawaii, New Jersey, North Dakota, Oregon, 

and Utah) had passed comprehensive smokefree indoor 

air laws that include e-cigarettes (CDC 2015a). These laws 

prohibit smoking and the use of e-cigarettes in indoor 

areas of private worksites, restaurants, and bars. Sixteen 

additional states had prohibited the use of e-cigarettes on 

some or all state property, and 475 local laws restricted 

e-cigarette use in 100% smokefree venues (Americans for 

Nonsmokers’ Rights Foundation 2015). Nationwide, more 

than 400 local jurisdictions prohibit e-cigarette use in 

100%-smokefree workplaces (Americans for Nonsmokers’ 

Rights Foundation 2015). Major cities that have addressed 

e-cigarettes include Austin, Boston, El Paso, Chicago, Los 

Angeles, Minneapolis, San Francisco, and New York City.
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 189

Table 5.2 Principle federal policies and regulations of tobacco that emphasize e-cigarettes

Agency

Authority and 

description Current Potential 

Executive Office 

of the President 

(EOP) and Office 

of Management 

and Budget 

(OMB)

— Executive Order 13058, issued on August 9, 1997 (EOP 1997), generally prohibits 

the smoking of tobacco products in all interior space owned, rented, or leased by 

the executive branch of the federal government, and in any outdoor areas under 

executive branch control in front of air intake ducts. The Executive Order carves 

out an exception to its smoking prohibition for any residential accommodation for 

persons voluntarily or involuntarily residing, on a temporary or long-term basis, 

in a building owned, leased, or rented by the federal government.

—

Executive Office 

of the President 

(EOP) and Office 

of the U.S. Trade 

Representative 

(USTR)

— Executive Order 13193, issued January 18, 2001 (EOP 2001), prohibits all U.S. 

executive branch agencies from promoting the sale or export of tobacco. It also 

prohibits using U.S. trade initiatives to restrict tobacco marketing and advertising 

regulations in other countries, unless those regulations discriminate against U.S. 

tobacco products in favor of that country’s domestic tobacco products.

—

Federal 

Communications 

Commission 

(FCC)

Has broad 

regulatory power 

over commercial 

communication, 

including television, 

radio, and the 

Internet. 

15 U.S.C. § 1335 (the “Broadcast Ban”), 15 U.S.C. § 4402(f): Prohibits advertising 

for cigarettes, little cigars, smokeless tobacco, and chewing tobacco on radio, TV, 

or any other medium of electronic communication under FCC’s jurisdiction.

Prohibit the advertising of smoking 

accessories, cigars, pipes, pipe tobacco, or 

cigarette-making machines on television; 

prohibit the advertising of e-cigarettes on 

television; and regulate the advertising of 

tobacco products on the Internet.

Federal Trade 

Commission 

(FTC)

Publishes annual 

report on tobacco 

products.

Reviews tobacco 

manufacturerproposed schedules 

to rotate mandatory 

package warnings.

Protects consumers.

Enforces antitrust 

laws.

15 U.S.C. § 46 authorizes FTC to require entities to file special reports. On an 

annual basis, FTC collects and publishes information on the practices of the 

largest manufacturers of cigarettes and smokeless tobacco in the United States. 

Among other things, the information collected includes sales and, in several 

categories, expenditures for marketing.

15 U.S.C. § 45: FTC has broad authority to prevent “unfair or deceptive” 

business practices. It is an unfair and deceptive act or practice for a firm to make 

unsubstantiated claims, express or implied, about such matters as a product’s 

efficacy, safety, or health benefits (FTC 1983).

FTC is broadly authorized to prevent companies from using “unfair methods of 

competition” that affect commerce. FTC uses its antitrust authority to review and 

impose conditions on those proposed mergers of tobacco companies that raise 

anticompetitive concerns.

Collect sales, advertising, and information 

on promotion expenditures from 

e-cigarette companies and issue reports 

on same.

Take enforcement action against unfair or 

deceptive advertising of tobacco products 

or e-cigarettes.
A Report of the Surgeon General

190 Chapter 5

Agency

Authority and 

description Current Potential 

General Services 

Administration 

(GSA)

In its role as an 

independent agency, 

GSA manages and 

maintains more 

than 1,550 federally 

owned buildings 

and leases space 

in an additional 

7,100 buildings in 

the United States. 

GSA manages 

the federal 

government’s 

automobile fleet and 

is the acquisition 

arm of the federal 

government.

GSA Order ADM, 5800. 1C: Smoking in GSA-occupied space and governmentowned or -leased vehicles assigned to GSA is prohibited “to protect GSA 

employees, GSA contractors, and the visiting public from exposure to tobacco 

smoke in the Federal workplace.” The Order prohibits smoking in or on all 

“interior GSA-occupied space, exterior GSA-occupied space, including courtyards, 

garages, loading docks, stairwells, rooftops and balconies, and other outdoor areas 

under GSA control within 25 feet of doorways and building air intake ducts; and 

government-owned or leased vehicles assigned to GSA” (U.S. General Services 

Administration 2009).

Clarify that existing policies include 

e-cigarettes.

Implement a tobacco-free campus policy 

in GSA-occupied space.

Office of 

Personnel 

Management 

(OPM)

— While not regulatory in nature, OPM and GSA coordinate standard responses to 

frequently asked questions about the use of e-cigarettes in government facilities.

—

U.S. Department 

of Agriculture 

(USDA)

Commodity and 

inspection standards 

for agricultural 

products.

Administers SNAP 

and WIC programs.

7 U.S.C. § 30: USDA provides commodity standards for tobacco.

7 U.S.C. § 2012: Under the Food and Nutrition Act of 2008, tobacco products 

cannot be purchased with SNAP benefits. ENDS are included in the policy because 

the USDA interprets ENDS to be tobacco products.

7 CFR 246.10: USDA identifies requirements for WIC-eligible foods. 

—

Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 191

Agency

Authority and 

description Current Potential 

U.S. Department 

of Defense (DoD)

May issue general 

instructions and 

restrictions in 

regulating the 

sale and/or use of 

tobacco products. 

Individual service 

branches may 

expand these 

regulations. 

Individual bases 

may also draft 

regulations. 

These typically 

are based on DoD 

instructions, 

directives, or service 

policies. DoD has 

authority over 

TRICARE.

DoD follows the smoking policy in federal facilities covered in 41 CFR 102-74.315, 

which states, “pursuant to Executive Order 13058, ‘Protecting Federal Employees 

and the Public From Exposure to Tobacco Smoke in the Federal Workplace’ it 

is the policy of the Executive Branch to establish a smokefree environment for 

federal employees and members of the public visiting or using federal facilities. 

The smoking of tobacco products is prohibited in all interior space owned, rented 

or leased by the Executive Branch of the federal government” (Federal Register

2008, p. 77518).

Each of the armed services has issued statements clarifying that the prohibition on 

smoking tobacco products extends to the use of e-cigarettes.

The 2015 NDAA directs the sale of cigarettes, cigars, and chewing tobacco at 

military commissaries. These items cannot be sold on military bases at prices 

lower than the most competitive prices in the local community. The NDAA 

replaced Directive 1330.09 (U.S. Department of Defense 2005), which established 

that tobacco prices on U.S. military bases should be no lower than 5% below the 

most competitive commercial price in the local community.

Branches of the armed services have tobacco policies:

• U.S. Navy and Marines, Instruction 5100.13E (U.S. Navy 2002)

• U.S. Army, Army Health Promotion Policy Regulation 600–63 (U.S. Army 1996)

• U.S. Air Force, Instruction 40-102, Air Force Tobacco Policy (U.S. Air Force 

2013)

TRICARE covers limited tobacco cessation counseling from any TRICAREauthorized provider in the United States. This coverage includes up to 

18 counseling sessions per quit attempt, with up to 4 individual counseling 

sessions per quit attempt. Two quit attempts per fiscal year are automatically 

covered, with coverage extending to a third with a doctor’s justification and 

pre-authorization. TRICARE also covers tobacco cessation products, including 

prescriptions and over-the-counter products, with 120 days’ use of a tobacco 

cessation product per quit attempt.

DoD-unified regulations on tobacco use in 

common housing.

Increased restrictions on commissary 

sales. 

Table 5.2 Continued
A Report of the Surgeon General

192 Chapter 5

Agency

Authority and 

description Current Potential 

U.S. Department 

of Education 

(ED)

Funding for tobacco 

control programs 

In FY 2014, pursuant to 20 U.S.C. § 7131, Safe and Drug-Free Schools and 

Communities Act, ED awarded the first round of 5-year grant awards under 

the School Climate Transformation Grant—Local Educational Agency Grants 

program. These FY 2014, Year 1 grant awards provided more than $35.8 million 

to 71 school districts in 23 states; Washington, DC; and the U.S. Virgin Islands. 

The funds should be used to develop, enhance, or expand systems of support for 

implementing evidence-based, multitiered behavioral frameworks for improving 

behavioral outcomes and learning conditions among students. The goals of the 

program are to connect children, youth, and families to appropriate services and 

supports; improve conditions for learning and behavioral outcomes for schoolaged youth; and increase awareness of mental health issues and the ability to 

respond to such issues among school-aged youth. School districts can also use 

the funds to implement models for reform and evidence-based practices. Drug 

prevention, including preventing tobacco use by youth, is an allowable activity. 

Grantees are encouraged, as part of their local needs assessment, to measure 

drug use among students along with other relevant issues and problems. This 

assessment of local needs will also be used by grantees to help identify and 

select the most appropriate evidence-based programs and practices. If the needs 

assessment indicates that drug abuse is an issue for students, prevention of drug 

abuse should be addressed by a multitiered behavioral framework.

—

U.S. Department 

of Education 

(ED)

Restrictions on 

tobacco use 

20 U.S.C. § 7181: The Pro-Children Act of 2001 prohibits smoking in any indoor 

facility that provides routine or regular kindergarten, elementary, or secondary 

education and library, health, or day care services to children, if such services 

and/or facilities are funded by the federal government, whether directly or through 

state or local governments, by federal grant, loan, loan guarantee, or contract 

programs.

—

Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 193

Agency

Authority and 

description Current Potential 

U.S. Department 

of Health 

and Human 

Services, Centers 

for Medicare 

& Medicaid 

Services (CMS) 

(continues on 

next page)

Sets policies 

regarding Medicaid 

coverage for tobacco 

cessation products 

and counseling.

42 U.S.C. § 1396r–8(d)(7): Tobacco cessation medications cannot be excluded from 

coverage under Medicaid prescription drug benefits. Section 2502 of the Affordable 

Care Act amends section 1927(d)(2) of the Social Security Act by removing 

barbiturates, benzodiazepines, and agents used to promote smoking cessation 

from the list of drugs that a state Medicaid program may exclude from coverage or 

otherwise restrict.

42 U.S.C. §§ 18021(a)(1)(B), 18022(b)(1): Tobacco use screening and cessation 

must be provided at no cost as an essential health benefit and a preventive benefit. 

This includes Medicaid expansion plans, plans sold on insurance exchanges, and 

private plans.

For youth: Tobacco cessation services are coverable as part of EPSDT, the Medicaid 

benefit for children and adolescents. EPSDT provides a comprehensive array of 

prevention, diagnostic, and treatment services for low-income infants, children, 

and adolescents under age 21, as specified in Section 1905I of the Social Security 

Act.

For pregnant women: Section 4107 of the Affordable Care Act amends 

section 1905 of the Social Security Act to require coverage of counseling and 

pharmacotherapy for cessation of tobacco use by pregnant women. Section 

1905(bb)(2) of the Social Security Act defines the new tobacco cessation coverage 

services for pregnant women as services recommended in the 2008 PHS Guideline, 

or any subsequent modification of this Guideline, and such other services that 

the Secretary recognizes to be effective for cessation of tobacco use by pregnant 

women.

Affordable Care Act, Section 4108, Medicaid Incentives for Chronic Disease 

Prevention Program: This is a grant program in which states apply for funds to 

incentivize Medicaid recipients to prevent chronic disease, including through 

tobacco cessation.

—

Table 5.2 Continued
A Report of the Surgeon General

194 Chapter 5

Agency

Authority and 

description Current Potential 

(continued from 

previous page) 

U.S. Department 

of Health 

and Human 

Services, Centers 

for Medicare 

& Medicaid 

Services (CMS)

— 42 U.S.C. § 1395x (ddd): Medicare covers tobacco cessation programs (Centers 

for Medicare & Medicaid Services 2010): Effective for claims with dates of service 

on or after August 25, 2010, CMS will cover tobacco cessation counseling for 

outpatient and hospitalized Medicare beneficiaries:

• Who use tobacco, regardless of whether they have signs or symptoms of 

tobacco-related disease;

• Who are competent and alert at the time that counseling is provided; and

• Whose counseling is furnished by a qualified physician or other Medicarerecognized practitioner.

Intermediate and intensive tobacco cessation counseling services are covered 

under Medicare Parts A and B when the above conditions of coverage are met, 

subject to frequency and other limitations. Medicare covers two individual 

tobacco cessation counseling attempts per 12-month period. Each attempt may 

include a maximum of four intermediate or intensive sessions, with a total benefit 

covering up to eight sessions per 12-month period per Medicare beneficiary who 

uses tobacco. The practitioner and patient have the flexibility to choose between 

intermediate (more than 3 minutes, up to 10 minutes) and intensive (more than 

10 minutes) cessation counseling sessions for each attempt. Medicare beneficiaries 

also have access to smoking cessation prescription medication through Medicare 

Part D.

—

U.S. Department 

of Health 

and Human 

Services, Centers 

for Medicare 

& Medicaid 

Services (CMS)

Sets policies 

regarding private 

and marketplace 

health plan 

coverage of tobacco 

cessation products 

and counseling.

42 U.S.C. §§ 18021(a)(1)(B), 18022(b)(1): Tobacco cessation must be provided at 

no cost as an essential health benefit. This includes Medicaid expansion plans, 

plans sold on insurance exchanges, and private plans.

42 U.S.C. § 300gg-6 (Public Law 114-38): Tobacco cessation must be covered 

in employer plans. Plans should cover two cessation attempts per year, 

including (1) all FDA-approved cessation medications (both prescription and 

over-the-counter) and (2) four tobacco cessation counseling sessions, including 

telephone, group, and individual counseling.

42 U.S.C. § 300gg(a)(1(iv)): Tobacco users may be charged 50% more for 

insurance than nonusers of tobacco.

42 U.S.C. § 300gg–4(j)-(k): Employers may reward or penalize employees by up to 

50% of the cost of health care coverage based on their tobacco use, if the employer 

offers a health-contingent wellness program designed to prevent or reduce tobacco 

use.

—

Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 195

Agency

Authority and 

description Current Potential 

U.S. Department 

of Health and 

Human Services, 

National 

Institutes of 

Health (NIH)

NIH is a tobaccofree campus.NIH’s policy specifically includes e-cigarettes. In accordance with the tobacco-free 

initiative from HHS, the use of cigarettes, e-cigarettes, cigars, pipes, smokeless 

tobacco (“snuff”), and any other tobacco product is prohibited on the NIH campus 

in Bethesda, MD (NIH 2016).

—

U.S. Department 

of Health and 

Human Services, 

National 

Institutes of 

Health, National 

Institute on 

Drug Abuse 

(NIDA), National 

Advisory Council 

on Drug Abuse 

(NACDA)

The mission 

of NIDA is to 

advance science 

on the causes and 

consequences 

of drug use and 

addiction and 

to apply that 

knowledge to 

improve individual 

and public health. 

NACDA serves 

crucial roles in 

advising NIDA on 

research priorities 

and policy and 

in providing a 

secondary level 

of review for 

applications under 

consideration for 

federal funding.

NIDA (2016) urges grantees to recognize that:

• Receiving funding from the tobacco industry may compromise the perceived 

objectivity of their research results, which in turn could impact the overall 

credibility of their research findings, including its interpretation, acceptance, 

and implementation;

• Acceptance of tobacco industry funds is viewed by many as contributing directly 

or indirectly to the industry’s interests, and thus harmful to the public health; 

and

• Any connection between tobacco industry-supported research (or tobacco 

industry scientists) and NIDA could negatively impact NIDA’s credibility and the 

public’s trust in NIDA-funded research.

—

Table 5.2 Continued
A Report of the Surgeon General

196 Chapter 5

Agency

Authority and 

description Current Potential 

U.S. Department 

of Health and 

Human Services, 

Substance Abuse 

and Mental 

Health Services 

Administration 

(SAMHSA)

Implements the 

Synar Amendment, 

which requires 

states, in order to 

receive their full 

Substance Abuse 

Prevention and 

Treatment Block 

Grant awards, 

to enact and 

enforce laws that 

prohibit the sale 

or distribution of 

tobacco products to 

individuals under 

the age of 18.

More information about the Synar Program is available online: http://www.

samhsa.gov/synar/about

SAMHSA is exploring opportunities to 

align the Synar regulation with the federal 

statutory definition of tobacco products, 

which includes e-cigarettes.

U.S. Department 

of Homeland 

Security (DHS)

Sales and use 

restrictions for the 

U.S. Coast Guard.

DHS Management 

DirectorateDirective No. 06603 

Smoking Policy. 

COMDTINST M6200.1B limits smoking to designated outdoor areas, prohibits use 

of tobacco by recruits, and prohibits tobacco use in any Coast Guard-controlled 

living quarters, including common areas. This policy includes extensive sales and 

advertising restrictions, but it does not consider NRT to be a tobacco product.

Implement a policy to enforce a ban on 

e-cigarette use on federal property.

U.S. Department 

of Homeland 

Security (DHS), 

Bureau of 

Immigration 

and Customs 

Enforcement 

(ICE)

Issues standards for 

facilities housing 

immigration 

detainees

Detainee smoking is prohibited in all buildings, including detainee-housing units. 

If smoking is permitted at a particular facility, the only designated smoking areas 

are outside of all buildings (Immigration and Naturalization Service 2000).

—

Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 197

Agency

Authority and 

description Current Potential 

U.S. Department 

of Housing 

and Urban 

Development 

(HUD)

Resident health in 

assisted housing

Public and Indian Housing (PIH) Notice 2009-21 strongly encourages HUD-funded 

public housing agencies to adopt smokefree policies in some or all of their public 

housing units.

Housing Notice 2010-21 encourages owners and management agents of HUDassisted multifamily housing to implement smokefree housing policies in one or 

all of the properties they own or manage.

Both notices focus on cigarettes that “burn” as their mechanism for generating 

smoke, and so their applicability to e-cigarettes is uncertain.

Regarding its Weaver Building headquarters (the only building for which GSA has 

designated HUD as the facility management authority), HUD follows GSA Order 

ADM 5800.1C, GSA’s smoking policy for federal offices (U.S. General Services 

Administration 2009). This GSA policy permits smoking in exterior space under 

GSA control that is beyond “25 feet of doorways and building air intake ducts,” 

except for “courtyards, garages, loading docks, stairwells, rooftops, and balconies.” 

The management of HUD’s other facilities, federally owned or leased, is not 

delegated to the Department, and so GSA makes the decision on smoking policy 

for those campuses.

HUD’s Office of PIH published its 

proposed rule on Instituting SmokeFree Public Housing (80 FR 71762) on 

November 17, 2015, accepting comments 

through January 19, 2016 (Federal 

Register 2015). In addition to inviting 

comments on all aspects of the proposed 

rule, the notice specifically solicited public 

comments on nine questions (e.g., should 

the policy extend to electronic nicotine 

delivery systems, such as e-cigarettes, 

and/or to waterpipe tobacco smoking?).

Based on responses to HUD’s Request for 

Information on Adopting Smoke-Free 

Policies in PHAs and Multifamily Housing 

(77 FR 60712) (Federal Register 2012), 

HUD may consider drafting a regulation 

or notice that could prohibit smoking 

in some or all HUD-assisted multifamily 

housing. Such a proposal could cover 

e-cigarettes.

HUD is beginning to prepare for the 

adoption and implementation of a 

campus-wide tobacco-free policy, which 

would include e-cigarette use, 

at the Weaver Building headquarters by 

January 1, 2017.

Table 5.2 Continued
A Report of the Surgeon General

198 Chapter 5

Agency

Authority and 

description Current Potential 

U.S. Department 

of Justice, 

Bureau of 

Alcohol, 

Tobacco, 

Firearms and 

Explosives (ATF)

ATF is given 

primary jurisdiction 

to combat cigarette 

trafficking and 

administration 

(via the CCTA) and 

to stop tobacco 

diversion (via the 

PACT).

18 U.S.C. § 2342: Under the CCTA, it is illegal to possess more than 10,000 

unstamped cigarettes in a state that requires a tax stamp.

18 U.S.C. § 2343: Any person who distributes more than 10,000 cigarettes must 

keep accurate records pertaining to the shipment, receipt, sale, and distribution of 

cigarettes.

18 U.S.C § 2320: Trafficking in counterfeit cigarettes.

15 U.S.C. § 375: It is illegal to ship cigarettes to a non-licensee in a state without 

notifying the state taxation authority.

15 U.S.C. § 375–377: Requires online retailers to check the identification of 

customers at purchase and delivery: section 375 covers definitions; section 

376 covers reports to state tobacco administrators; and section 377 covers 

penalties.

The Smuggled Tobacco Prevention (STOP) Act amends the IRC to restrict the sale, 

lease, export or import, or delivery of tobacco production machines to persons 

lawfully engaged in (1) the sale, lease, export or import, or delivery of such 

machines; (2) the manufacture or packaging of tobacco products or processed 

tobacco; or (3) the application of unique identification markings onto tobacco 

products or processed tobacco packages.

—

U.S. Department 

of Justice, 

Bureau of 

Prisons (BOP)

BOP has authority 

to govern the 

control and 

management 

of federal penal 

and correctional 

institutions.

28 C.F.R. § 551.162: Smoking is generally prohibited in and on the grounds of 

BOP institutions and offices, with exceptions for smoking as part of an authorized 

inmate religious activity, and for smoking only in smoking areas designated by the 

warden, for BOP staff and official visitors.

28 C.F.R. § 551.163: Possession of smoking apparatus and tobacco in any form is 

prohibited for inmates, unless as part of an authorized inmate religious activity.

BOP Operations Memorandum 006-

2015 (BOP 2015) sets out guidelines 

for e-cigarette use. Guidelines state 

that e-cigarette use is to be limited 

to designated outdoor areas that are 

reasonably accessible to employees and 

provide a measure of protection from the 

elements. These areas may only be used by 

employees, but must be separate from the 

areas presently designated as “smoking 

areas” for use of tobacco products. Indoor 

use of e-cigarettes shall not be permitted 

in BOP facilities, except in perimeter 

towers and perimeter patrol vehicles when 

occupied by one person.

Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 199

Agency

Authority and 

description Current Potential 

U.S. Department 

of Labor, 

Occupational 

Safety and 

Health 

Administration 

(OSHA)

Sets standards for 

indoor air quality.

29 CFR 1910.1000, Air Contaminants: This policy restricts employee exposure to 

several of the main chemical components found in tobacco smoke. OSHA rules 

apply to tobacco smoke only in rare and extreme circumstances, such as when 

contaminants created by a manufacturing process combine with tobacco smoke 

to create a dangerous air supply that fails OSHA standards for the workplace. In 

normal situations, exposures would not exceed permissible exposure limits and, as 

a matter of prosecutorial discretion, OSHA will not apply the General Duty Clause 

to environmental tobacco smoke.

Have smokefree workplaces. In the 

1990s, OSHA proposed a regulation 

setting indoor air quality standards for 

environmental tobacco smoke, but this 

rulemaking was terminated (Federal 

Register 2001).

U.S. Department 

of Transportation 

(DOT)

Sets restrictions 

on tobacco use on 

commercial and 

personal aircraft.

49 U.S.C. § 41706: Prohibits smoking on passenger flights.

14 CFR Part 252: DOT rule implementing 49 U.S.C. § 41706, and prohibiting 

smoking on most passenger flights. DOT interprets current Part 252 to include 

e-cigarettes in smokefree policies.

Note: FAA regulations also prohibit smoking on most aircraft from an aircraft 

safety perspective, not from a health perspective (see notes to 14 CFR Part 252).

In early 2016, DOT issued a final rule 

(RIN 2105-AE06). In keeping with 

section 41706, the rule amends Part 252 

to prohibit smoking on charter flights 

where a flight attendant is a required crew 

member. The rule also makes explicit the 

determination that the use of e-cigarettes 

falls within the definition of smoking.

DOT’s Pipeline and Hazardous Materials 

Safety Administration has proposed a rule 

to prohibit the charging of e-cigarettes in 

an aircraft cabin, and to prohibit stowage 

of e-cigarettes in the cargo hold of an 

aircraft (this is a hazardous material/safety 

rule, not a health/tobacco rule).

Table 5.2 Continued
A Report of the Surgeon General

200 Chapter 5

Agency

Authority and 

description Current Potential 

U.S. Department 

of Treasury, 

Alcohol and 

Tobacco Tax and 

Trade Bureau 

(TTB)

TTB administers the 

provisions of the 

Internal Revenue 

Code (IRC) of 1986, 

as amended, that 

impose federal 

excise taxes on 

tobacco products 

and cigarette 

papers and tubes, 

and it establishes 

a comprehensive 

civil and criminal 

framework to 

protect the revenue.

Among other issues, 

TTB investigates 

illegal production, 

underreporting 

of production, 

smuggling 

or unlawful 

importation, 

and diversion of 

domestic tobacco 

products intended 

for export.

26 U.S.C. 26 § 5701–5763, Tobacco Products and Cigarette Papers and Tubes: 

Under the IRC, the tobacco products that are subject to tax and TTB regulation 

are cigars, cigarettes, smokeless tobacco (chewing tobacco and snuff), pipe 

tobacco, and roll-your-own tobacco. Each of these tobacco products is defined with 

reference to “tobacco.” TTB also has regulatory authority over processed tobacco, 

which is not subject to tax. TTB regulations define processed tobacco to mean 

any tobacco that has undergone processing but that does not include tobacco 

products. The processing of tobacco includes, but is not limited to, stemming 

(i.e., removing the stem from the tobacco leaf); fermenting, threshing, cutting, 

or flavoring the tobacco; or otherwise combining the tobacco with nontobacco 

ingredients.

To protect revenue, the IRC and its implementing regulations establish 

qualification criteria to engage in businesses related to manufacturing, importing, 

or exporting tobacco products or in manufacturing or importing processed 

tobacco, and they require that persons obtain permits to engage in these activities. 

Under the IRC, manufacturers of tobacco products and export warehouse 

proprietors must file a bond that relates to the tax liability for the tobacco 

products on the premises covered by the permit. The IRC and implementing 

regulations also include recordkeeping and reporting requirements designed to 

ensure that TTB can verify that the tax on tobacco products is paid or determined 

or that adequate documentation exists to confirm that a tax exemption applies. 

The IRC also provides TTB with certain enforced-collection options (e.g., liens and 

levies), civil and criminal penalties, permit suspension and revocation procedures, 

and forfeiture provisions to ensure that the tax is collected.

ENDS that do not contain nicotine derived from tobacco are not tobacco products 

under the IRC and are not subject to taxation or TTB regulation. ENDS containing 

nicotine derived from tobacco may meet the definition of a tobacco product under 

the IRC, in which case they would be regulated by TTB and taxed accordingly.

TTB will collaborate with foreigncounterpart tax administrators to share 

information and best practices in the 

administration of tobacco excise taxes 

and their enforcement. Areas of possible 

technical assistance include setting up an 

auditing system and permitting regimen 

and conducting investigations.

TTB’s tobacco laboratory provides 

technical assistance to TTB program 

offices on tobacco products for regulatory 

compliance and enforcement purposes. 

TTB’s tobacco laboratory develops and 

validates analytical methods and protocols 

on tobacco products. It also collaborates 

with national and international tobacco 

regulatory federal agencies and has 

established a collaborative partnership 

with the World Health Organization’s 

Tobacco Laboratory Network and the 

North America Tobacco Regulatory 

Laboratory Network.

Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 201

Agency

Authority and 

description Current Potential 

U.S. Department 

of Veterans 

Affairs (VA)

Can restrict the 

use of e-cigarettes 

and combustible 

cigarettes on facility 

grounds of the 

Veterans Health 

Administration to 

designated outdoor 

smoking areas only.

Public Law 102-585: Requires medical centers, nursing homes, and domiciliary 

care facilities of the Veterans Health Administration to establish smoking areas for 

patients and residents in a way that is consistent with medical requirements and 

limitations.

Include language about restrictions on the 

use of e-cigarettes in local and national 

guidance regarding smokefree policies.

U.S. Department 

of Veterans 

Affairs (VA)

Provides evidencebased tobacco 

cessation treatment 

to veterans 

receiving care in 

the VA health care 

system.

38 CFR Part 17: Eliminated in 2006 the copayment for smoking cessation 

counseling for veterans in care facilities of the Veterans Health Administration 

(Federal Register 2006).

Continue to provide clinical guidance 

for the health care professionals and 

patients in facilities of the Veterans Health 

Administration on the evidence base of 

(a) potential health effects of e-cigarettes 

and (b) comparisons to FDA-approved 

NRT for cessation treatment.

U.S. 

Environmental 

Protection 

Agency (EPA)

Sets policies 

regarding the 

hazardous 

waste status of 

e-cigarettes under 

the RCRA.

Nicotine is a commercial chemical product listed in 40 CFR 261.33(e) and is an 

acute hazardous waste (EPA waste code P075) when disposed. EPA has concluded 

that nicotine is the sole active ingredient of the e-liquid in e-cigarettes and thus 

a commercial chemical product, that e-cigarettes are not manufactured articles, 

and that e-cigarette cartridges are considered containers of nicotine. Therefore, 

e-cigarettes may be regulated as acute hazardous waste code P075 when disposed. 

If the nicotine e-liquid is legitimately recycled, it is not considered a solid 

waste under 261.2 because it is considered a commercial chemical product, and 

therefore it is not subject to hazardous waste regulation. E-cigarettes that are 

disposed of by consumers at their residences are considered exempt household 

hazardous waste under 261.4(b)(1) and are not subject to regulation as hazardous 

waste under the federal RCRA regulations.

• Regulatory Citation(s): 261.2, 261.4(b)(1), 261.33.

• Statutory Citation(s): 3006 Read U.S. Code 42, Chapter 82.

—

Note: ATF = Bureau of Alcohol, Tobacco, Firearms and Explosives; BOP = Bureau of Prisons; CCTA = Contraband Cigarette Trafficking Act; CFR = Code of Federal 

Regulations; CMS = Centers for Medicare & Medicaid Services; DHS = U.S. Department of Homeland Security; DoD = U.S. Department of Defense; DOT = U.S. Department 

of Transportation; ED = U.S. Department of Education; ENDS = electronic nicotine delivery systems; EOP = Executive Office of the President; EPA = U.S. Environmental 

Protection Agency; EPSDT = Early and Periodic Screening, Diagnosis and Treatment; FAA = Federal Aviation Administration; FCC = Federal Communications 

Table 5.2 Continued
A Report of the Surgeon General

202 Chapter 5

Commission; FDA = Food and Drug Administration; FTC = U.S. Federal Trade Commission; FY = fiscal year; GSA = General Services Administration; 

HUD = U.S. Department of Housing and Urban Development; ICE = Bureau of Immigration and Customs Enforcement; IRC = Internal Revenue Code; NACDA = National 

Advisory Council on Drug Abuse; NDAA = National Defense Authorization Act; NIDA = National Institute on Drug Abuse; NIH = National Institutes of Health; 

NRT = nicotine replacement therapy; OMB = Office of Management and Budget; OPM = Office of Personnel Management; OSHA = Occupational Safety and Health 

Administration; PACT = Prevent All Cigarette Trafficking Act; PHS = Public Health Service; PIH = Public and Indian Housing; RCRA = Resource Conservation and 

Recovery Act; SAMHSA = Substance Abuse and Mental Health Services Administration; SNAP = Special Supplemental Nutrition Program; TTB = Alcohol and Tobacco Tax 

and Trade Bureau; U.S.C. = United States Code; USDA = U.S. Department of Agriculture; USTR = U.S. Trade Representative; VA = U.S. Department of Veterans Affairs; 

WIC = Women, Infants, and Children.

Table 5.2 Continued
E-Cigarette Policy and Practice Implications 203

E-Cigarette Use Among Youth and Young Adults

Prevent Youth Access

Ensuring that laws on youth access include 

e-cigarettes is intended to protect youth from exposure 

to nicotine, which can lead to addiction and other health 

problems. Additionally, ensuring that these laws include 

e-cigarettes helps to capture the full diversity of the 

tobacco product landscape, including combustible, noncombustible, and electronic tobacco products. Effective 

strategies to deter access to e-cigarettes by youth and the 

use of these products in this population include restricting 

sales of e-cigarettes to minors, requiring verification of 

age, mandating clear signage about minimum age where 

sales take place, prohibiting the sale of e-cigarettes from 

vending machines, eliminating self-service displays of 

e-cigarettes, and actively enforcing existing laws with a 

focus on retailers. Compliance with laws that regulate 

the sale and distribution of e-cigarettes is facilitated by 

requiring retailers to be licensed. To date, 46 states have 

prohibited the sale of e-cigarettes to minors younger than 

a specified age (National Conference of State Legislatures 

2015; The Council of State Governments 2015). Federally, 

aligning youth tobacco access control regulations with 

the statutory definition of tobacco products in the Tobacco 

Control Act, which includes e-cigarettes, could provide 

consistent framework to help ensure that restrictions on 

youth access to e-cigarettes are prioritized and enforced 

(Federal Register 2016). This could include modifications 

to the Synar regulation, which requires states, U.S. territories, and jurisdictions to enact and enforce laws prohibiting the sale or distribution of tobacco products to 

youth. Substance Abuse Prevention and Treatment Block 

Grant recipients must comply with the Synar amendment 

and implement regulations in order to receive their full 

awards (U.S. Food and Drug Administration, Center for 

Tobacco Products n.d.).

Licensing

Licensing is used to regulate professional practice 

and business operations and represents one strategy to control the rising use of e-cigarettes among youth. In general, 

in the case of tobacco-related licensing, a business is authorized to manufacture, distribute, or sell tobacco products 

as long as it complies with all relevant laws (McLaughlin 

2010). Typically, tobacco-related licensing requirements 

for retailers and/or manufacturers help to prevent evasion 

of excise taxes, ensure that licensees comply with tobaccorelated laws, and promote safe manufacturing practices 

(ChangeLab Solutions 2012). Repeat violators of relevant 

laws may be subject to suspension or permanent revocation 

of their license, an outcome that provides a strong incentive 

to comply with existing requirements. As in the conventional cigarette industry, licensing of e-cigarette retailers 

and manufacturers is designed in part to prevent the use 

of these products by youth and to facilitate safe manufacturing practices. Unlike traditional tobacco products, for 

which retailers sell prepackaged products and the number 

of manufacturers is limited, a growing number of businesses engage in both the retail sale and manufacturing of 

devices and liquids used in the devices (e-liquids). Stores 

devoted exclusively to the sale of e-cigarettes are known as 

“vape shops.” These shops frequently offer a social environment for using products, and they may also sell food and 

beverages (Sussman et al. 2014).

As of April 2015, 99 cities and counties in California 

required a retailer to obtain a license to sell e-cigarettes. 

The majority of these jurisdictions did so by broadening 

the definition of tobacco products to include “electronic 

smoking devices” (ChangeLab Solutions 2015a). The 

definition was purposely broadened to include products that do not include nicotine to decrease the complexity of enforcement and in recognition of the fact 

that e-cigarette devices are sometimes used with liquids 

that do not contain nicotine but may contain marijuana 

oil (The Center for Tobacco Policy & Organizing 2015a). 

Licensing requirements also may be used to restrict the 

sale of flavored products or to address issues of consumer 

and worker safety relative to the mixing of e-liquids.

Imposing a moratorium is another potential 

approach that has been used in some communities to stop 

new “vape shops” from entering the market while a more 

comprehensive approach was being considered. A moratorium is a land-use law that takes effect immediately to stop 

temporarily the issuance of a business license, building 

permit, or use permit. Typically, a moratorium is enacted 

to provide a jurisdiction with time to research and study 

how to regulate a type of business (ChangeLab Solutions 

2015b). In California, several communities enacted moratoria that are initially 45 days but can be extended for 

up to 2 years (ChangeLab Solutions 2014, 2015b). A fourfifths vote, however, is required to establish a moratorium 

in California. Hayward and Union City, California, are 

examples of cities that have enacted moratoria and later 

adopted both retail licensing requirements for existing 

e-cigarette retailers and zoning restrictions to prohibit 

new vapor and hookah bars and lounges from opening 

within city limits (ChangeLab Solutions 2014; The Center 

for Tobacco Policy & Organizing 2015b).
A Report of the Surgeon General

204 Chapter 5

Taxation and Other Price Policies

Taxation and other price policies directed at making 

e-cigarettes more expensive may be implemented at multiple levels of government, from local to federal. Increasing 

the price of conventional cigarettes, including those 

increases resulting from excise taxes, significantly prevents 

and reduces tobacco use, particularly among youth and 

young adults (USDHHS 2014), and has potentially more 

impact on prevalence of current use in this population than 

on first use (Bader et al. 2011). Similarly, price policies are 

likely to reduce the use of e-cigarettes: a 10% increase in 

the price of e-cigarettes has been estimated to reduce sales 

of disposable e-cigarettes by approximately 12% and reusable products by about 19% (Bader et al. 2011; Huang et al. 

2014). Data are currently lacking on the potential effects 

that taxing e-cigarettes might have on conventional cigarettes. Tobacco products are taxed in two main ways:

1. A “specific” excise tax is levied based on the quantity 

of the product sold (e.g., as measured by number of 

cigarettes, weight, or volume). This type of mechanism applies the same tax across low-end and premium brands and is generally simple to administer. 

The disadvantages to specific excise taxes are that 

the real value of the tax declines over time with 

inflation, making products more affordable, and 

that super-lightweight products—such as snus, 

orbs, sticks, and dissolvables—are grossly undertaxed if the tax is based on weight (Freiberg 2012; 

Boonn 2013; Shang et al. 2015).

2. The second tax mechanism is an ad valorem excise 

tax, which is levied on a percentage of the value of 

the tobacco product (e.g., the retailer’s, wholesaler’s, or manufacturer’s price). This type of tax keeps 

up with inflation and establishes a flat tax rate across 

all brands, product types, weights, and packaging. 

The disadvantages to this kind of tax include the 

potential for tax evasion through predatory (belowcost) or anticompetitive pricing; increasing the 

price differential between products with different 

pretax prices, leading to greater price variability and 

more opportunity for tax avoidance; a governmentprovided subsidy for manufacturers’ price cuts; and 

more expensive brands being subjected to a larger 

tax (Freiberg 2012; Boonn 2013; Shang et al. 2015). 

Governments use uniform, tiered, and mixed-tax 

approaches to implement specific and ad valorem tobacco 

excise taxes. Uniform systems apply the same tax rate 

across all products; tiered systems levy taxes based on 

such product characteristics as toxicity, nicotine content, 

type of production (handmade versus machine made), 

sales volume, packaging, or whether the products are 

domestic or imported; and mixed systems use a combination of uniform and tiered-tax approaches (Shang et al. 

2015). Tiered-tax approaches, such as those based on nicotine content, could steer consumers to a less toxic product 

or one with lower nicotine (Benowitz 2014). Tiered-tax 

approaches are more complex to administer and may 

provide greater opportunity for tax evasion as a result of 

manipulation of the product or its packaging by the manufacturer (Shang et al. 2015). In recognition of nicotine’s 

toxicity, particularly to youth, several health groups have 

endorsed imposing excise taxes on e-cigarettes to discourage their use by youth (American Thoracic Society 

2013; Association of State and Territorial Health Officials 

2014; Bhatnagar et al. 2014; Brandon et al. 2015a; Crowley 

and Health Public Policy Committee of the American 

College of Physicians 2015; National Association of 

County and City Health Officials 2014). E-cigarettes are 

likely less toxic than combustible products (such as conventional cigarettes), and therefore, some contend should 

be taxed at a lower rate (Benowitz 2014; Bhatnagar et al. 

2014). Yet others argue that e-cigarettes should be taxed 

at the same rate as other tobacco products (Freiberg 2012; 

American Thoracic Society 2013; National Association of 

County and City Health Officials April 2014).

As of January 2016, four states (Kansas, Louisiana, 

Minnesota, and North Carolina) and six localities (Juneau, 

Matanuska-Susitna, Petersburg, and Sitka, Alaska; 

Montgomery County, Maryland; and Chicago, Illinois) 

had enacted e-cigarette taxation policies. Minnesota’s 

ad valorem tobacco tax equates to 95% of the wholesale 

cost of any product containing or derived from tobacco 

(Minnesota Revenue 2014; Tobacco Control Legal 

Consortium 2015). It taxes e-liquids and e-cigarettes 

sold with nicotine cartridges that cannot be removed 

(i.e., disposables). In Minnesota, devices without a nicotine cartridge are not taxed as a tobacco product. On the 

other hand, North Carolina applies a specific excise tax, 

taxing e-liquids based on volume at 5 cents per milliliter 

(National Conference of State Legislatures 2015).

The Tobacco Control Legal Consortium, which 

is based at William Mitchell College of Law in St. Paul, 

Minnesota, recommends using an ad valorem tax for 

e-cigarettes applied at the retail level to the “essential” 

components of these devices. The tax is simple, captures 

both disposable and refillable devices, and could exclude 

accessories and universal parts sold separately, such 

as batteries or charging cords (Tobacco Control Legal 

Consortium 2015).

Numerous major health organizations support 

raising the price of e-cigarettes through non-tax options, 

such as limiting rebates, discounts, and coupons (Freiberg 
E-Cigarette Policy and Practice Implications 205

E-Cigarette Use Among Youth and Young Adults

2012; Association of State and Territorial Health Officials 

2014; Bhatnagar et al. 2014; Huang et al. 2014; Brandon 

et al. 2015a).

Finally, Chaloupka and colleagues (2015) have proposed that differential taxation of tobacco products can 

be used to incentivize a move away from combustible 

products to less hazardous noncombustible products, 

including e-cigarettes. They have argued that taxation 

could be part of a harm-reduction system. In their view, 

future determinations by FDA as to whether a product 

poses a substantially reduced risk would be one criterion 

in determining the relative rate of taxation.

Restrictions on Marketing

As described in Chapter 4, the marketing of 

e-cigarettes drives consumer demand for these products. Such marketing also may promote misperceptions 

about the safety and efficacy of these products for use 

as cessation devices (Choi and Forster 2014; Mark et al. 

2015; Pokhrel et al. 2015). For some populations—such 

as pregnant women, adolescents, former smokers, and 

young adults—the adverse health consequences of nicotine intake are substantial. Several groups have supported 

extending marketing restrictions that apply to conventional cigarettes and other tobacco products to e-cigarettes 

(Association of State and Territorial Health Officials 2014; 

Bam et al. 2014; Bhatnagar et al. 2014; Partnership for 

Prevention 2014; Brandon et al. 2015a). Significant barriers still exist to regulating commercial speech, including 

the First Amendment rights of the e-cigarette companies 

(Laird-Metke 2010).

Additionally, for traditional tobacco products, partial 

advertising bans and voluntary agreements have generally been ineffective in reducing consumption because the 

tobacco industry circumvents the restrictions by shifting 

the marketing platforms used to unregulated platforms 

(National Cancer Institute 2008). This response would 

be expected to be similar with regard to e-cigarettes. 

Therefore, despite the numerous barriers, public health 

groups and state, local, tribal, and territorial governments 

should take steps to stem the proliferation of e-cigarette 

marketing likely to appeal to young people by using tools 

designed to curb youth-oriented tobacco marketing and 

expanding evidence to inform future restrictions on the 

marketing of e-cigarettes to youth and young adults.

Surveillance of e-cigarette marketing, performing 

content analyses of the messages used, and conducting 

studies to assess the link between exposure to e-cigarette 

marketing and the use of e-cigarette products, particularly 

among youth and young adults, will facilitate the development of an evidence base of the type that informed prior 

federal and Master Settlement Agreement restrictions on 

tobacco advertising. Observations of retailers’ practices, 

assessments of outdoor advertising, and identification 

of event sponsorships and promotional activities at bars 

and community events are actions that state, local, tribal, 

and territorial public health agencies have taken related 

to traditional tobacco products. Many of these actions 

can be adapted to monitor and document the presence of 

e-cigarette marketing in communities (Pucci et al. 1998; 

Feighery et al. 2001; Rigotti et al. 2005; Roeseler et al. 2010; 

Rose et al. 2014).

In the absence of legal restrictions on e-cigarette 

marketing, and apart from the issue of the previous promulgation by some companies of unsubstantiated health 

and cessation claims, public health groups can advocate 

for television and radio broadcasters, print and outdoor 

media companies, the management of event venues and 

sports events, digital media outlets, retailers, and others 

to voluntarily refuse to air or place e-cigarette advertising, 

offer sponsorships, or give out free samples at fairs and festivals. Although the impact of a voluntary approach may 

be low, such actions raise awareness, build concern, and 

help to denormalize the proliferation of e-cigarette marketing. In California, surveillance plus voluntary efforts 

to promote restrictions on sponsorship of events by the 

tobacco industry facilitated a modest decline in tobacco 

industry-sponsored events and youth-oriented activities 

at those events that promoted the interests of the tobacco 

companies, and it led to a productive partnership with the 

tobacco litigation unit of the California attorney general’s office that resulted in several settlements with tobacco 

companies (Roeseler et al. 2010).

State, local, tribal, and territorial public health 

agencies may be able to contribute to the stimulation 

of enforcement and compliance with existing rules that 

constrain marketing. Some states have brought lawsuits 

against e-cigarette companies, alleging that distributors 

of these products violated state law by selling to minors 

or making unsubstantiated health claims; some of those 

lawsuits resulted in financial damages and agreements to 

stop making claims that e-cigarettes are safer than conventional cigarettes unless confirmed by rigorous science 

(Center for Public Health and Tobacco Policy 2013).

 Finally, another area to address is the use of “advertorials” employed by e-cigarette retailers to promote 

cessation and health claims. Advertorials are paid advertisements designed to look like an independent editorial. 

Although there are no specific rules for how a publisher 

should distinguish actual editorial content from paid editorial content in terms of their appearance, the Federal 

Trade Commission (FTC) stated in an advisory opinion 

that disclosure of the source is necessary when content 

“uses the format and has the general appearance of a news 
A Report of the Surgeon General

206 Chapter 5

feature and/or article for public information which purports to give an independent, impartial and unbiased view” 

(Federal Register 1972, p. 154). Additionally, paid advertising must be disclosed clearly and conspicuously in a 

manner that is understandable to consumers (FTC 1984). 

State and local public health agencies can play an important role by monitoring and providing substantiation to 

their state attorney general or FTC regarding advertising 

that makes improper claims or is not clearly identified as 

advertising.

Educational Initiatives

The extensive data reviewed in Chapter 2 highlighted the limited knowledge that members of the general public, particularly adolescents and young adults, 

have about e-cigarettes and their potential for nicotine 

addiction and other adverse health consequences. FDA 

has jurisdiction for product warnings that can reach 

users, but that agency, along with other federal entities 

and state and local governmental and nongovernmental 

organizations, can also carry out educational campaigns 

to enhance such limited knowledge levels. Potentially 

effective initiatives with youth and young adults to prevent 

smoking were reviewed in the 2012 Surgeon General’s 

report and may be applicable to preventing e-cigarette 

use. That report concluded that sufficient evidence exists 

to conclude that mass media campaigns, comprehensive 

community programs, comprehensive statewide tobacco 

control programs, and school-based programs that have 

shown evidence of effectiveness, if they contain specific 

components, can produce at least short-term effects and 

reduce the prevalence of tobacco use among school-aged 

youth (USDHHS 2012).

Implications for Health Care 

Practice

Although the issues are not well documented, health 

care practitioners face questions about e-cigarettes from 

their patients and their communities, including what are 

the risks of using e-cigarettes, how do these risks compare 

with those of cigarettes or other combustible products, 

and is e-cigarette use an effective way to quit smoking? 

Chapter 3 set out the limited evidence base related to 

these questions. Clinicians need to respond to these questions and guide their patients in the context of considerable uncertainty. At this time, practitioners can turn to 

the various statements from medical organizations, which 

generally urge caution regarding e-cigarettes and do not 

find the evidence to be supportive of their use for cessation or for formal harm-reduction strategies (Table 5.3). 

In fact, any recommendation to use e-cigarettes for the 

cessation of smoking is not supported by the bulk of 

the available scientific evidence (Hartmann-Boyce et al. 

2016). Both the American Association of Cancer Research 

and the American Society of Clinical Oncology recommend against advising the use of e-cigarettes for cessation (Brandon et al. 2015b). The U.S. Preventive Services 

Task Force found that there is insufficient evidence that 

e-cigarettes are an effective smoking cessation tool in 

adults, including pregnant women (Agency for Healthcare 

Research and Quality 2015).

The clinical care setting is a critical venue for taking 

evidence-based approaches for enhancing smoking cessation and increasing the protection of susceptible groups 

against exposure to secondhand smoke (USDHHS 2014). 

However, research on e-cigarettes in relation to this set of 

venues is lacking and urgently needed. Regardless, some 

pragmatic approaches have been proposed. For example, 

the American Academy of Pediatrics (AAP) gives advice 

on how pediatricians can approach questioning about the 

use of e-cigarettes. As of October 2015, the AAP’s position 

on e-cigarettes is that sales to minors should be prohibited; flavors that appeal to youth should be prohibited; 

and measures against the use of e-cigarette products need 

to be included in requirements for maintaining smokefree environments, such as in restaurants and workplaces 

(AAP 2015a).
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 207

Table 5.3 Medical organizations

A. Positions of professional organizations

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

American 

Academy of 

Pediatrics 

(2015b)

— • “Concentrated nicotine solution 

for electronic nicotine delivery 

systems should be sold in 

child-resistant containers with 

amounts limited to that which 

would not be lethal to a young 

child if ingested.”

• “Prohibitions on smoking and 

use of tobacco products should 

include prohibitions on use of 

electronic delivery systems.”

• “The promotion and sale of electronic nicotine delivery 

systems to youth should be prohibited by federal, state, and 

local regulations.”

• “Prohibitions on promotion should include all media that can 

be viewed by youth, including broadcast, print, and electronic 

(Web- or Internet-based) media.”

• “Prohibitions on promotion should include prohibitions 

on sponsorships, such as sports, cultural event, and 

entertainment sponsorships. Any promotional activities that 

can be accessed by children and/or adolescents should be 

considered promoting to children.”

• “Electronic nicotine delivery systems should be subject 

to the same restrictions on advertising and promotion at 

least as restrictive as that on combustible cigarettes. Until 

government agencies institute these prohibitions, media 

companies, entertainment companies, sports teams, and 

promoters should voluntarily institute these prohibitions.”

• “Celebrities should not use their privileged position to model 

tobacco product use, including electronic nicotine delivery 

systems and other existing or emerging tobacco products.”

—
A Report of the Surgeon General

208 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

American 

Association 

for Cancer 

Research 

(AACR) and 

the American 

Society of 

Clinical 

Oncology 

(2015)

(continues 

on next 

page)

• FDA has not 

approved e-cigarettes 

as smoking cessation 

aids, and current 

data are inconclusive 

with regard to their 

efficacy as quitsmoking products.

• “Oncologists would 

be wise to refrain 

from recommending 

e-cigarettes to 

patients as a firstline therapy for 

smoking cessation.”

• “The evidence regarding the 

risks and benefits of e-cigarettes 

is difficult to interpret, and data 

on the long-term consequences 

of e-cigarette use are not yet 

available.”

• “Chemicals and ultrafine 

particles known to be toxic 

and carcinogenic and/or to 

cause respiratory and heart 

distress have been identified in 

e-cigarettes.”

• “Studies find the levels of the 

toxicants in e-cigarette aerosol 

to be significantly lower than in 

cigarette smoke and, in many 

cases, comparable with trace 

amounts found in a medicinal 

nicotine inhaler. It is unclear 

what effects these toxicants 

might have on e-cigarette users 

after chronic and frequent use.”

• “The vast majority of e-cigarette 

users use products containing 

nicotine. Nicotine is an addictive 

chemical, adversely affects 

maternal and fetal health 

during pregnancy, has adverse 

consequences for fetal brain 

development, and may adversely 

affect the adolescent brain. It 

is unclear what effect nicotine 

intake via e-cigarettes has on 

health or on the addictiveness of 

these products.”

• “The FDA CTP should regulate all ENDS that meet the 

statutory definition of tobacco products and their component 

parts. ENDS delivery systems and e-liquids containing 

tobacco-derived nicotine should be regulated whether they 

are sold together or separately.”

• “ENDS manufacturers should be required to register with 

FDA and report all product and ingredient listings, as well as 

the nicotine concentration in the ENDS solution.”

• “ENDS packaging and advertising should be required to 

carry health warnings and safety labels—including a warning 

regarding nicotine addiction.”

• “Youth-oriented ENDS advertising and marketing should 

be prohibited, including: self-service ENDS displays, the 

provision of gifts and other giveaways with purchase of ENDS, 

the sale and distribution of items such as hats or t-shirts 

with ENDS brand logos, brand name sponsorship of social or 

cultural events, or of any team entry into those events, and 

youth-oriented advertising of tobacco products.”

• “Internet and other mail-order sellers of ENDS should be 

required to check the age and identification of customers at 

the point of purchase and delivery; to comply with all laws 

in the purchaser’s state or local jurisdiction; and pay all 

applicable federal, state, and local taxes.”

• “Childproof caps should be required for all e-liquid 

containers.”

• “ENDS and ENDS liquid containing candy and other youthfriendly flavors should be banned unless there is evidence 

demonstrating that these products do not encourage youth 

uptake.”

• “ENDS use should be prohibited in places where combustible 

tobacco product use is prohibited by federal, state, or local 

law until the safety of second- and thirdhand aerosol exposure 

is established.”

• “There are 

insufficient data on 

health consequences 

of e-cigarette use, 

their value as tobacco 

cessation aids, and 

their effects on the 

use of combustible 

tobacco products 

by smokers and 

nonsmokers.”

• “Oncologists should 

advise all smokers 

to quit smoking 

combustible 

cigarettes, encourage 

use of FDAapproved cessation 

medications, refer 

patients for smoking 

cessation counseling, 

and provide 

education about 

the potential risks 

and lack of known 

benefits of long-term 

e-cigarette use.”

Table 5.3 A Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 209

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

(continued 

from 

previous 

page) 

American 

Association 

for Cancer 

Research 

(AACR) and 

the American 

Society of 

Clinical 

Oncology 

(2015)

— • “Data from the [CDC] showed 

a significant increase in 

e-cigarette-related calls to poison 

centers between 2010 and 2014 

as a result of accidental ingestion 

or absorption of e-cigarette 

liquid.”

• “Secondhand exposure to 

toxicants and nicotine from 

e-cigarette aerosol has been 

documented, though there are 

not current data suggesting 

that exposure to the aerosol has 

adverse health effects.”

• “There are no published 

studies evaluating thirdhand 

(i.e., residue that builds up on 

surfaces over time) exposure 

to e-cigarette aerosol in indoor 

environments, although 

preliminary data suggest that 

nicotine from e-cigarettes can 

stick to surfaces.”

• “Funding generated through tobacco product taxes, including 

any potential taxes levied on ENDS, should be used to help 

support research on ENDS and other tobacco products, but 

should not preclude the allocation of federal funding for this 

research.”

• “All data related to ENDS composition, use, and health effects 

should be disclosed for dissemination and independent review 

as well as to enhance policy decisions for ENDS product 

regulation.”

• “Tobacco products should be taxed proportionate to their 

harm; therefore, ENDS should not be taxed at equal or higher 

rates than combustible cigarettes.”

• “State and local governments should implement ENDS 

regulations within their authorities that are appropriate for 

protecting the public health, including restricting the sale, 

distribution, marketing, and advertising of ENDS to youth.”

• “International cooperation is needed to develop standards 

for the regulation of ENDS, and these regulations should 

prioritize protection of the public’s health and draw upon the 

best available scientific evidence whenever possible.”

—

American 

Association 

for 

Respiratory 

Care (AARC) 

(2015)

• “Even though the 

concept of using 

the e-cigarettes for 

smoking cessation 

is attractive, they 

have not been fully 

studied and the 

use among middle 

school children is 

increasing year after 

year.”

• “There is no evidence as to the 

amount of nicotine or other 

potentially harmful chemicals 

being inhaled during use or if 

there are any benefits associated 

with using these products.”

— • Date effective: April 

2014

• “The [AARC] opposes 

the use of the 

electronic cigarette 

(e-cigarette).”

Table 5.3 A Continued
A Report of the Surgeon General

210 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

American 

College of 

Physicians 

(ACP) 

(Crowley 

and Health 

Public Policy 

Committee 

of the ACP 

2015)

• “ENDS, which 

include electronic 

cigarettes, or 

e-cigarettes, 

are growing in 

popularity, but their 

safety and efficacy as 

a smoking cessation 

aid are not well 

understood.”

• “[There is concern] that the 

health effects of ENDS use are 

unknown, that they may appeal 

to young people, and that they 

may encourage dual use of 

ENDS and traditional tobacco 

products.”

• “The Food and Drug Administration [should] extend its 

regulatory authority granted through the Family Smoking 

Prevention and Tobacco Control Act to cover electronic 

nicotine delivery systems (ENDS).”

• “Characterizing flavors should be banned from all tobacco 

products, including ENDS.”

• “The [ACP] supports taxing tobacco products, including 

ENDS devices and nicotine liquids, to discourage use among 

children and adolescents. Local governments should be 

permitted to establish higher tax rates for ENDS and related 

products than state levels.”

• “The [ACP] supports legislative or regulatory efforts to 

restrict promotion, advertising, and marketing for ENDS 

products in the same manner as for combustible cigarettes, 

including a prohibition on television advertising.”

• “Youth tobacco prevention efforts, such as antismoking media 

campaigns and school-based interventions, should include 

information about the potential risks of ENDS use.”

• “The federal, state, and local regulators should take action to 

extend indoor and public place clean air laws that prohibit 

smoking in public places, places of employment, commercial 

aircraft, and other areas to ENDS products.”

• “The federal government should authorize and appropriate 

funding to rigorously research the health effects of ENDS 

use, chemical content, and toxicity; effects of ENDS vapor 

exposure; dual-use rates; and effects of ENDS-derived nicotine 

on human health.”

• “The [ACP] supports 

strong regulations to 

ensure product safety 

and transparency, 

policies that prevent 

use among young 

people, increased 

research to better 

determine their 

health effects, strong 

limits on marketing 

and promotion to 

discourage interest 

among young people, 

and application of 

indoor air laws to 

protect the health of 

bystanders.”

• “This paper is not 

intended to offer 

clinical guidance or 

serve as an exhaustive 

literature review 

of existing ENDSrelated evidence but 

to help direct the 

[ACP], policymakers, 

and regulators on 

how to address these 

products.”

Table 5.3 A Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 211

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

American 

Thoracic 

Society 

(2013, 2015)

(continues 

on next 

page)

• “The new CDC 

data show that Big 

Tobacco is once 

again peddling a new 

product intended to 

get youth hooked 

on nicotine, and 

that e-cigarettes 

are not about 

harm reduction or 

smoking cessation, 

but about addiction.”

• “The short- and long-term health 

risks of these nicotine-delivery 

devices are largely unknown.”

• “States should regulate e-cigarettes as tobacco products. 

E-cigarettes should not be sold to those younger than 18, and 

regulations requiring identification and proof of age at the 

time of purchase should apply. Internet sales of e-cigarettes 

should be strictly regulated.”

• “E-cigarettes should be taxed at rates equivalent with 

traditional cigarettes and other tobacco products.”

• “E-cigarettes should be subject to the same restrictions 

regarding public use as combustible tobacco products, and 

e-cigarettes should not be used in smoke-free areas.”

• “The FDA should deem regulatory authority over 

e-cigarettes.”

• “Candy and menthol flavored e-cigarettes should be banned.”

• “E-cigarette packaging should include warning labels, similar 

in size and scope to those required of combustible tobacco 

packaging. Where risks are known, the consumer should be 

informed of those risks in clear and direct language. Where 

data regarding risk is [sic] unavailable or inconclusive, the 

consumer should be informed of the lack of reliable safety 

testing data.”

• “The FDA should regulate the form and content of e-cigarette 

advertising.”

• “Both direct and implied health and safety claims by 

e-cigarette manufacturers should be subject to the same 

evidentiary review process currently required for other 

products making such claims.”

• “The FDA should require e-cigarette manufacturers to adopt 

Good Manufacturing Processes similar to those that exist for 

other regulated products, including lot numbers, securing 

packaging, etc.”

• “Given that nicotine is an addictive drug, with the dependence 

liability related to the pharmacokinetic characteristics of 

the delivery device, delivery characteristics of the e-cigarette 

should be evaluated and disclosed, and periodically monitored 

to ensure consistency of the product’s dependence potential 

over time.”

• “[E]-cigarettes need 

to be subject to the 

same marketing 

and manufacturing 

restrictions as 

tobacco products.”

• “For the first time, 

e-cigarette use 

among young people 

is higher than for 

any other tobacco 

product.”

Table 5.3 A Continued
A Report of the Surgeon General

212 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

(continued 

from 

previous 

page) 

American 

Thoracic 

Society 

(2013, 2015)

— — • “Content of e-cigarette cartridges should be disclosed and 

regulated.”

• “The nicotine content of the e-cigarette cartridge should not 

exceed that of similar user volume of combustible tobacco.”

• “Deliverable nicotine levels should be consistent between 

cartridges.”

• “Researchers and clinicians, along with scientific societies 

and publications, receiving funding from e-cigarette 

manufacturers should disclose this relationship and the 

potential for conflict of interest in a manner equivalent to 

disclosures required for funding from the remainder of the 

tobacco industry.”

—

Table 5.3 A Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 213

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

European 

Respiratory 

Society 

(ERS) (2014)

• “Electronic 

cigarettes are 

designed for the 

purpose of direct 

nicotine delivery 

to the respiratory 

system, and they fall 

into a regulatory gap 

in most countries, 

escaping regulation 

as medicinal 

products and 

avoiding the controls 

applicable to tobacco 

products.”

• “For ERS, the priority of the 

Revision of the Tobacco Products 

Directive is to protect children 

and youth from becoming 

smokers by preventing them 

from picking up their first 

cigarette.”

• “There is no adequate scientific 

research available on the overall 

health risk or the long-term 

effects of electronic cigarette use 

on humans.”

• “Mandatory reporting system of ingredients used in tobacco 

products.”

• “Harmonised regulation of the ingredients of tobacco 

products.”

• “80% pictorial health warnings, covering the front and back 

of packages. Based on evidence, the larger the pictorial health 

warnings are, the more effective they are.”

• “Plain/standardised packaging of tobacco products.”

• “Introduction of both visible and invisible security features on 

tobacco packaging and ensuring that the storage and access 

to such data is [sic] independent from tobacco companies.”

• “Prohibition on the cross-border distance sale of tobacco 

products.”

• “Strong regulatory framework and independent research for 

electronic cigarettes. Any regulation of electronic nicotine 

delivery systems should be science based.”

• “Ensuring the adoption of delegated acts is not exposed to the 

interests of the tobacco industry, which would jeopardise the 

achievement of high level of health protection.” 

• “ERS supports 

the European 

Commission’s 

Proposal for the 

Tobacco Products 

Directive and 

Rapporteur Linda 

McAvan’s efforts to 

improve it.”

• “Introduction of 

standard packs with 

increased health 

warnings.”

• “Prohibition of 

characterizing 

flavours.”

• “Strengthening 

of traceability and 

security features for 

combating illicit 

trade.”

• “Prohibiting 

misleading features, 

including slim 

cigarettes.”

• “Approximately 

700,000 EU citizens 

die prematurely 

every year because 

of tobacco 

consumption.”

Table 5.3 A Continued
A Report of the Surgeon General

214 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

Forum of 

International 

Respiratory 

Societies 

(American 

College 

of Chest 

Physicians 

2014; 

Schraufnagel 

et al. 2014)

• “Studies looking at 

whether electronic 

cigarettes can 

aid smoking 

cessation have had 

inconsistent results.”

• “The safety of electronic 

cigarettes has not been 

adequately demonstrated.”

• “The addictive power of nicotine 

and its untoward effects should 

not be under-estimated.

• “Potential benefits to an 

individual smoker should be 

weighed against harm to the 

population of increased social 

acceptability of smoking and use 

of nicotine.”

• “Adverse health effects for third 

parties exposed to the emissions 

of electronic cigarettes cannot be 

excluded.”

• “Health and safety claims regarding electronic nicotine 

delivery devices should be subject to evidentiary review.”

• “If ENDS devices are permitted, they should be regulated as 

tobacco products.”

• “Research, supported by sources other than the tobacco 

or electronic cigarette industry, should be carried out to 

determine the impact of electronic nicotine delivery devices 

on health in a wide variety of settings.”

• “The use and population effects of END devices should be 

monitored.”

• “All information derived from this research should be 

conveyed to the public in a clear manner.”

• “ENDS should be 

restricted or banned, 

at least until more 

information about 

their safety is 

available.”

Table 5.3 A Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 215

B. Voluntary health organizations

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

American 

Cancer 

Society 

(ACS) (2014)

• “Because the 

American Cancer 

Society doesn’t 

yet know whether 

e-cigarettes are safe 

and effective, we 

cannot recommend 

them to help people 

quit smoking.”

• “There are proven 

methods available 

to help people quit, 

including pure forms 

of inhalable nicotine 

as well as nasal 

sprays, gums, and 

patches.”

• “[E]-cigarettes are not labeled 

with their ingredients, so the 

user doesn’t know what’s in 

them.”

• “Inhaling a substance is not the 

same as swallowing it.”

• “Studies have shown that 

e-cigarettes can cause short-term 

lung changes that are much 

like those caused by regular 

cigarettes.”

• “E-cigarettes need to be researched and regulated.” • “Until electronic 

cigarettes are 

scientifically 

proven to be safe 

and effective, 

ACS will support 

the regulation of 

e-cigarettes and laws 

that treat them like 

all other tobacco 

products.”

Table 5.3 Continued
A Report of the Surgeon General

216 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

American 

Heart 

Association 

(AHA) 

(Bhatnagar 

et al. 2014)

(continues 

on next 

page)

• “Current evidence 

evaluating the 

efficacy of these 

products as a 

cessation aid is 

sparse, confined 

to 2 randomized 

controlled trials 

and 1 large crosssectional study, 

anecdotal reports, 

and Internet-based 

surveys.”

• “[R]eports are 

confounded by a 

self-selection bias in 

that the respondents 

are often e-cigarette 

enthusiasts.”

• “The AHA maintains 

that e-cigarette 

use should be 

part of tobacco 

screening questions 

incorporated into 

clinical visits and 

worksite/community 

health screenings 

that are tied into 

healthcare delivery.”

• “Low levels of harmful or 

potentially harmful metals such 

as lead, nickel, and chromium 

are listed as having been 

detected.”

• “Trace levels of tobacco-specific 

N-nitrosamines, polycyclic 

aromatic hydrocarbons, and 

volatile organic compounds in 

the e-liquid and vapor have been 

reported.”

• “The FDA has issued warnings 

to several e-cigarette companies 

for selling e-cartridges with 

[diethylene glycol, weightloss chemical rimonabant 

(Zimulti), and the erectile 

dysfunction medication tadalafil 

(active ingredient in Cialis)] 

contaminants.”

• “There are no reports of 

e-cigarette safety in patients with 

known cardiovascular disease.”

• “The regulation should allow for quality-controlled products 

for adults who want to transition from conventional cigarettes 

to e-cigarettes or to quit or reduce smoking.”

• “Bottles containing nicotine refill liquids can be toxic if 

swallowed, so cartridges and bottles should have proper 

warning labeling and child-proofing packaging.”

• “It is important that the relevant government agency monitor 

whether these devices are used for delivery of other drugs and 

medications.”

• “Companies should not be able to claim that e-cigarettes are 

a cessation aid unless they are approved by the FDA for that 

purpose.”

• “The [AHA] supports 

effective regulation 

that addresses 

marketing, labeling, 

quality control of 

manufacturing, 

and standards for 

contaminants.”

• “[It] also supports 

including 

e-cigarettes in 

smoke-free air laws 

and prohibiting the 

sales of e-cigarettes 

to youth.”

Table 5.3 B Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 217

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

(continued 

from 

previous 

page) 

American 

Heart 

Association 

(AHA) 

(Bhatnagar 

et al. 2014)

• “Clinicians should 

be educated about 

e-cigarettes and 

should be prepared 

to counsel their 

patients who are 

using combustible 

tobacco products to 

use e-cigarettes as 

a primary cessation 

aid.”

• “For patients 

with existing 

cardiovascular 

disease and stroke, 

or at risk of a 

cardiovascular 

disease event, 

intensive cessation 

counseling should 

be offered as soon as 

possible.”

— — —

Table 5.3 B Continued
A Report of the Surgeon General

218 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

American 

Lung 

Association 

(2014, 2015)

• “Until and unless 

the FDA approves a 

specific e-cigarette 

for use as a tobacco 

cessation aid, the 

American Lung 

Association does not 

support any direct 

or implied claims 

that e-cigarettes help 

smokers quit.”

• “There is currently no scientific 

evidence establishing the safety 

of e-cigarettes.”

• “FDA found detectable levels of 

toxic cancer-causing chemicals, 

including an ingredient used in 

anti-freeze, in two leading brands 

of e-cigarettes and 18 various 

cartridges.”

• “The lab tests also found that 

cartridges labeled as nicotinefree had traceable levels of 

nicotine.”

• “Nicotine is believed to 

contribute to increased incidence 

of premature birth, and low birth 

weight.”

• “Research has also shown a 

negative impact on pulmonary 

function in newborns.”

• “The FDA has not approved any e-cigarettes as a safe or 

effective method to help smokers quit.”

• “Including 

e-cigarettes in 

smokefree laws and 

ordinances.”

• “State laws that 

would prohibit the 

sale of any flavored 

e-cigarette product.”

• “Taxing e-cigarettes 

at a rate equivalent 

with all tobacco 

products, including 

cigarettes.”

• “Eliminating 

e-cigarette sales to 

youth, otherwise 

restricting youth 

access to e-cigarettes 

and requiring 

e-cigarette retailers 

to be licensed.”

• “E-cigarettes should 

be defined as tobacco 

products.”

• “Opposes creating 

new definitions for 

‘vapor products’ 

and/or ‘alternative 

nicotine products’ in 

state laws.”

Table 5.3 B Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 219

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

Americans 

for 

Nonsmokers’ 

Rights (ANR) 

(n.d.a; n.d.b)

• “ESDs are not 

proven cessation 

devices.”

• “Many people 

become ‘stable 

dual-users’ who use 

both cigarettes and 

ESDs.”

• “Americans for Nonsmokers’ 

Rights recommends that 

e-cigarettes not be used in areas 

where people will be exposed to 

the vapors they emit.”

• “Electronic smoking device 

aerosol is not water vapor. . . . 

The aerosol (incorrectly called 

vapor) contains nicotine, 

hazardous ultrafine particles that 

lodge deeply in the lungs . . . and 

toxins known to cause cancer.”

• “Electronic smoking devices are currently unregulated 

products.”

• “[ANR] . . . encourages municipalities and states to prohibit 

the use of ESDs in all smokefree venues.”

• “Electronic cigarettes 

are not a safe 

alternative!”

C. World Health Organization

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

World Health 

Organization 

(WHO) (Bates 

2014; WHO 

2014b)

(continues on 

next page)

• “Prohibit 

manufacturers and 

third parties from 

making health 

claims for ENDS, 

including that 

ENDS are smoking 

cessation aids.”

• “The regulatory 

standard for 

cessation claims 

and approval as 

cessation aids 

should remain an 

appropriate body 

of evidence, based 

on well-controlled 

clinical trials.”

• “ENDS users should be legally 

requested not to use ENDS 

indoors, especially where smoking 

is banned until exhaled vapour 

is proven to be not harmful 

to bystanders and reasonable 

evidence exists that smokefree policy enforcement is not 

undermined. If smoke-free 

legislation is not fully developed 

according to Article 8 of the WHO 

FCTC and the guidelines for its 

implementation, this should be 

done as soon as possible.”

• “Health warnings should be 

commensurate with proven health 

risks.”

• “Parties should contemplate putting in place an effective 

restriction on ENDS advertising, promotion and sponsorship.”

• “Protection from vested commercial interests.”

• “Governments are recommended to use or strengthen their 

existing tobacco surveillance and monitoring systems to assess 

developments in ENDS and nicotine use by sex and age.”

• “Overall, in 

its public 

communication 

WHO portrays 

e-cigarettes as a 

threat to public 

health.”

• “Encourage 

smoking cessation 

and provide a 

quitline number if 

one exists.”

Table 5.3 B Continued
A Report of the Surgeon General

220 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

(continued 

from previous 

page) 

World Health 

Organization 

(WHO) (Bates 

2014; WHO 

2014b)

• “For ENDS 

products to be 

approved for 

smoking cessation 

by the suitable 

regulatory agency, 

the appropriate 

balance should 

be reached 

between providing 

accurate scientific 

information 

to the public 

about the risk of 

ENDS use and its 

potential benefits 

as compared with 

smoking.”

— — —

Table 5.3 C Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 221

Table 5.3 Continued

D. Government health

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

European 

Union (EU) 

(European 

Parliament 

and Council 

2014; WHO 

Framework 

Convention 

on Tobacco 

Control 2014)

— • “Certain additives used to create 

the impression that tobacco 

products have health benefits, as 

well as those with [carcinogenic, 

mutagenic, or reprotoxic] 

properties in unburnt form, 

should be prohibited in order to 

ensure uniform rules throughout 

the Union and a high level of 

protection of human health.”

• “Electronic cigarettes and 

refill containers could create a 

health risk when in the hands 

of children—it is necessary to 

ensure products are child and 

tamperproof.”

• “Nicotine-containing liquid should 

only be placed on the market in 

electronic cigarettes or in refill 

containers that meet certain safety 

and quality requirements.”

• “The prohibition of tobacco products with characterizing 

flavours does not preclude the use of individual additives 

outright, but it does oblige manufacturers to reduce the 

additive or the combination of additives.”

• “Electronic cigarettes and refill containers should be 

regulated by this Directive.”

• “Where the manufacturer of the relevant product is not 

established in the Union, the importer of that product should 

bear the responsibilities relating to the compliance of those 

products with this Directive.”

• “Nicotine-containing liquid should only be allowed to be 

placed on the market, where the nicotine concentration does 

not exceed 20 mg/ml.”

• “Only electronic cigarettes that deliver nicotine doses at 

consistent levels should be allowed to be placed on the 

market.”

• “The labeling and packaging of [e-cigarettes] should display 

sufficient and appropriate information on their safe use.”

• New directive: May 

2014.

• New rules applied: 

First half of 2016.

• “Aims at ensuring 

equal treatment 

across the EU for 

nicotine-containing 

e-cigarettes 

(products that do 

not contain nicotine 

are not covered by 

the Directive).”

• “Electronic 

cigarettes can 

develop into 

a gateway to 

nicotine addiction 

and ultimately 

traditional tobacco 

consumption, as 

they mimic and 

normalize the 

action of smoking. 

For this reason, it 

is appropriate to 

adopt a restrictive 

approach to 

advertising 

electronic 

cigarettes and refill 

containers.”
A Report of the Surgeon General

222 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

CAP/BCAP 

(UK) (2014)

— • “Ads cannot convey health benefits 

or claim that they are safer or 

healthier than smoking tobacco.”

• “Ads must not be likely to appeal particularly to people under 

18, especially by reflecting or being associated with youth 

culture.”

• “People shown using e-cigarettes or playing a significant role 

must neither be, nor seem to be, under 25.”

• “Ads must not be directed at people under 18 through the 

selection of media or the context in which they appear.”

• “Ads must not encourage nonsmokers or nonnicotine users to 

use e-cigarettes.”

• “Ads must make clear that the product is an e-cigarette and 

not a tobacco product.”

• “Ads on TV and radio will be subject to scheduling restrictions 

to reduce the chance of e-cigarette advertisements being seen 

or heard by children.”

• Effective date: 

November 10, 2014.

• “The rules place an 

emphasis on the 

protection of young 

people and ads must 

avoid containing 

anything that 

promotes the use of 

a tobacco product 

or that shows the 

use of a tobacco 

product in a positive 

light.”

• CAP: Write and 

maintain the UK 

advertising codes.

Public Health 

England (UK) 

(Britton and 

Bogdanovica 

2014; 

CAMQUIT 

n.d.)

— — • “Under the terms of the new Tobacco Product Directive 

(TPD) . . . advertising of nicotine-containing devices that are 

not licensed as medicines will be prohibited, products will be 

required to carry health warnings, meet purity and emission 

standards that are yet to be defined.”

• Effective date: 2016.

• “The UK [Medicines 

and Healthcare 

products Regulatory 

Agency] announced 

that from 2016, it 

intended to regulate 

electronic cigarettes 

and other nicotinecontaining products 

as medicines by 

function, and 

thus require 

manufacture to 

medicinal purity 

and delivery 

standards, and 

proactive controls 

on advertising.”

Table 5.3 D Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 223

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

International 

Union Against 

Tuberculosis 

and Lung 

Cancer (2013)

• “The benefits 

of e-cigarettes 

have not been 

scientifically 

proven.”

• “Very few studies 

have assessed ECs/

ENDS as a harm 

reduction and 

cessation aid and 

with conflicting 

findings.”

• “The safety of ECs or ENDS has not 

been scientifically demonstrated.”

• “Adverse health effects for 

[secondhand smoke] cannot 

be excluded because the use of 

electronic cigarettes leads to 

emission of fine and ultrafine 

inhalable liquid particles, nicotine 

and cancer-causing substances into 

indoor air.”

• “A range of current and proposed legislative and regulatory 

options exists.”

• “Brazil, Norway, and Singapore have banned ECs/ENDS 

completely.”

• “ENDS could undermine the implementation of WHO FCTC 

Article 12 (de-normalisation of tobacco use).”

• “Use of ENDS could also hamper the implementation of 

Article 8 (protection from exposure to tobacco smoke).”

• “The Union 

strongly supports 

the regulation of 

the manufacture, 

marketing and 

sale of Electronic 

cigarettes (ECs) 

or electronic 

nicotine delivery 

systems (ENDS); 

the preferred option 

is to regulate 

ECs or ENDS as 

medicines.”

• “The Union is 

concerned that 

the marketing, 

awareness and use 

of ECs or ENDS is 

growing rapidly.”

Note: AARC = American Association for Respiratory Care; ACP = American College of Physicians; ACS = American Cancer Society; AHA = American Heart Association; 

ANR = Americans for Nonsmokers’ Rights; CAP/BCAP = Committees of Advertising Practice/Broadcast Committee of Advertising Practice; CDC = Centers for Disease 

Control and Prevention; CTP = Center for Tobacco Products; ECs = electronic cigarettes; ENDS = electronic nicotine delivery systems; ERS = European Respiratory 

Society; ESDs = electronic smoking devices; EU = European Union; FCTC = Framework Convention for Tobacco Control; FDA = U.S. Food and Drug Administration; 

UK = United Kingdom; WHO = World Health Organization.

Table 5.3 D Continued
A Report of the Surgeon General

224 Chapter 5

Case Studies

Case studies in California and North Dakota demonstrate how e-cigarette policies have been enacted at the 

local and state levels, and they provide potential models 

of how cities, counties, and other states might address 

e-cigarettes in their jurisdictions.

City of Hayward Takes Bold Steps to Address Tobacco Products Aimed 

at Kids

In response to the “D” grade that the city of Hayward received in 2011 from the American Lung Association in 

California for its efforts to protect youth from tobacco sales, the city council directed its staff to develop regulations 

to address the problem of youth tobacco sales. Draft regulations were presented at a city planning meeting in 2012, 

followed by a series of community meetings and hearings that culminated in the Hayward city council’s adoption of 

a 45-day moratorium to begin in January 2014 on the issuance of business licenses or building permits for any new 

tobacco retailers. The following month, the moratorium was extended another 15 months to provide more time to 

research and consider the issue (City of Hayward 2014).

On July 1, 2014, the Hayward city council unanimously adopted an ordinance that requires sellers of tobacco 

products and “electronic smoking devices” to obtain annually a $400 tobacco retailer license that covers the cost of 

an annual inspection for compliance with federal, state, local, tribal, and territorial tobacco control laws. The ordinance allowed the city’s existing 142 tobacco retailers, 8 e-cigarette retailers, and 2 hookah lounges to continue 

operating at their current locations; however, new sellers must obtain a conditional use permit, are restricted to special commercial zones, and may not locate within 500 feet of residential areas or child-sensitive areas (e.g., schools 

and parks) or within 500 feet of an existing tobacco seller. It also prohibits new hookah lounges or vaping lounges 

from opening within the city.

The ordinance also contains provisions to prohibit self-service displays of tobacco products and e-cigarettes 

and to regulate the sales of cigars, flavored products, and imitation tobacco products. Cigars selling for less than 

$5 each are required to be sold in pack sizes of five or more, and the sale of flavored traditional tobacco products, 

e-cigarettes, and imitation tobacco products (e.g., candy cigarettes, bubble gum chew) is prohibited within 500 feet 

of schools for any business not selling these products before July 1, 2014.

Penalties range from $1,500 for a first violation and possible suspension to a complete revocation of a license 

after three violations within a 3-year period (City of Hayward 2014; n.d.a.). Active enforcement of the ordinance 

began in April 2015 (City of Hayward n.d.b.).

Throughout the process, Hayward officials and staff relied heavily on materials from the American Lung 

Association, the Center for Tobacco Policy and Organizing, and ChangeLab Solutions to provide the public health 

and legal rationale for supporting the provisions. Hayward’s tobacco retail licensing effort was also supported by 

the tobacco control program of the Alameda County public health department, which used monies from its Master 

Settlement Agreement to fund the Hayward police department to conduct youth decoy operations and local community and youth organizations to conduct educational outreach (City of Hayward 2014). Collectively, these resources 

informed the Hayward city council’s decision-making process.
E-Cigarette Policy and Practice Implications 225

E-Cigarette Use Among Youth and Young Adults

North Dakota’s Statewide Clean Indoor Air Law Prohibits Conventional 

Tobacco Products and E-Cigarettes

In November 2012, North Dakota achieved a remarkable victory for statewide clean indoor air (BreatheND 

n.d.a.) despite major obstacles, including a harsh winter climate, an adult smoking rate of 21.9% (CDC 2013), and 

several prior failed legislative attempts to close exemptions in the state’s 2005 clean indoor air law (CDC 2014). 

Despite these impediments, two-thirds of the state voted to prohibit both the smoking of conventional tobacco products and use of e-cigarettes in all non-hospitality workplaces; restaurants; bars; hotel guest rooms and communal 

areas; health care facilities; assisted living facilities; all licensed child and adult day care facilities; gaming facilities; indoor areas of sports arenas; and within 20 feet of entrances, exits, operable windows, air intakes, and ventilation systems of enclosed areas where smoking is not allowed (BreatheND n.d.b.). Additionally, the law provided 

no exemptions for tobacco-only retail or “vape shops” (Americans for Nonsmokers’ Rights Foundation 2015, n.d.).

The 2012 ballot initiative on statewide clean indoor air resulted from the lack of progress in working with the 

legislature to try to close smoking exemptions in the state law. The initiative’s sponsors, Tobacco Free North Dakota 

and the American Lung Association in North Dakota, worked closely with the Tobacco Control Legal Consortium 

to draft policy language, which included prohibiting the use of e-cigarettes anywhere smoking was prohibited. The 

sponsors approached stakeholders and assessed public support. Little opposition was encountered to prohibiting the 

use of e-cigarettes indoors. In addition to the sponsors’ efforts, the North Dakota Center for Tobacco Prevention and 

Control Policy conducted a media campaign and worked with local partners to educate their communities, resulting 

in 11 smokefree ordinances prior to the issuing of the statewide ballot initiative. The landslide victory (66% vs. 33%) 

in favor of clean indoor air, with the initiative successfully carried in every one of North Dakota’s 53 counties, demonstrated widespread public support for clean indoor air (Ballotpedia 2012).

Only a few years later, the law continues to enjoy strong public support from nonsmokers (84.4%) and smokers 

(58%) alike. Compliance with the law is comparable to cigarette smoking; just 16.8% of North Dakotans reported 

having observed smoking indoors in areas where it was prohibited, and 23.2% reported having seen e-cigarettes 

used indoors in such places. Local enforcement personnel confirm a high level of compliance, reporting violations 

primarily related to smoking within 20 feet of entrances. To date, the only prosecuted violation of the law involved 

the sampling of an e-cigarette product inside a “vape shop” (BreatheND 2014). In hindsight, the decision to include 

e-cigarettes in North Dakota’s smokefree law was helpful, given increasing concerns about involuntary exposure to 

nicotine and other aerosolized e-cigarette emissions.

Summary and Recommendations

The Surgeon General has long played a leading role 

in identifying the harms of tobacco use and documenting 

the most effective ways to reduce them. This report comes 

amid the rising use of e-cigarettes among the nation’s 

youth and young adults. It calls attention to this problem 

and the need to implement immediately a comprehensive 

strategy to minimize any negative public health impact 

now and in the future, giving consideration to the potential 

for youth to be harmed from e-cigarettes while, simultaneously, acknowledging that gains might be made if the use 

of combustible tobacco products fell among adult smokers. 

Chapters 1–4 documented the particular challenges posed 

by the rapid emergence and dynamic nature of e-cigarette 

use among youth and young adults. The marketplace is 

diverse, and although it includes the large tobacco companies, e-cigarettes are sold in thousands of “vape shops” 

and other small commercial locations and on the Internet. 

Marketing strategies exploit social media, reaching widely 

and with tailored targeting to consumers.

The differences notwithstanding, the principles and 

strategies articulated in the 2014 Surgeon General’s report 

and prior reports remain relevant to e-cigarettes. The 2014 

report was written not long after the use of e-cigarettes 

began to surge dramatically; that report commented on the 

need for rapid elimination of conventional cigarettes and 

other combustible tobacco products but did not specify 

a role for e-cigarettes or discuss strategies to minimize 

adverse effects among youth and young adults (USDHHS 

2014). The report’s final chapter, however, set out an evidence-based strategy for the future. The present report 

builds on this foundation, adding recommendations related 

to e-cigarettes.
A Report of the Surgeon General

226 Chapter 5

Conclusions

1. The dynamic nature of the e-cigarette landscape 

calls for expansion and enhancement of tobaccorelated surveillance to include (a) tracking patterns 

of use in priority populations; (b) monitoring the 

characteristics of the retail market; (c) examining 

policies at the national, state, local, tribal, and territorial levels; (d) examining the channels and messaging for marketing e-cigarettes in order to more 

fully understand the impact future regulations 

could have; and (e) searching for sentinel health 

events in youth and young adult e-cigarette users, 

while longer-term health consequences are tracked.

2. Strategic, comprehensive research is critical to 

identify and characterize the potential health risks 

from e-cigarette use, particularly among youth and 

young adults.

3. The adoption of public health strategies that are precautionary to protect youth and young adults from 

adverse effects related to e-cigarettes is justified.

4. A broad program of behavioral, communications, 

and educational research is crucial to assess how 

youth perceive e-cigarettes and associated marketing messages, and to determine what kinds of 

tobacco control communication strategies and 

channels are most effective.

5. Health professionals represent an important 

channel for education about e-cigarettes, particularly for youth and young adults.

6. Diverse actions, modeled after evidence-based 

tobacco control strategies, can be taken at the 

state, local, tribal, and territorial levels to address 

e-cigarette use among youth and young adults, 

including incorporating e-cigarettes into smokefree policies; preventing the access of youth to 

e-cigarettes; price and tax policies; retail licensure; 

regulation of e-cigarette marketing that is likely to 

attract youth and young adults, to the extent feasible 

under the law; and educational initiatives targeting 

youth and young adults. Among others, research 

focused on policy, economics, and the e-cigarette 

industry will aid in the development and implementation of evidence-based strategies and best 

practices.
E-Cigarette Policy and Practice Implications 227

E-Cigarette Use Among Youth and Young Adults

References

Abrams DB. Promise and peril of e-cigarettes: can disruptive technology make cigarettes obsolete? JAMA: 

the Journal of the American Medical Association

2014;311(2):135–6.

Agency for Healthcare Research and Quality. Final 

Recommendation Statement: Tobacco Smoking 

Cessation in Adults and Pregnant Women: Behavioral 

and Pharmacotherapy Interventions. Rockville (MD): 

U.S. Preventive Services Task Force, 2015.

Allen JG, Flanigan SS, LeBlanc M, Vallarino J, MacNaughton 

P, Stewart JH, Christiani DC. Flavoring chemicals in 

e-cigarettes: diacetyl, 2,3-pentanedione, and acetoin in 

a sample of 51 products, including fruit-, candy-, and 

cocktail-flavored e-cigarettes. Environmental Health 

Perspectives 2016;124(6):733–9.

American Academy of Pediatrics. Policy statement: 

electronic nicotine delivery systems. Pediatrics

2015a;136(5):1018–26.

American Academy of Pediatrics. Public policy to protect 

children from tobacco, nicotine, and tobacco smoke. 

Pediatrics 2015b;136(5):998–1007.

American Association for Cancer Research, American 

Society of Clinical Oncology. Regulating electronic 

cigarettes and other ENDS, 2015; <http://www.

aacr.org/AdvocacyPolicy/GovernmentAffairs/Pages/

recommendations-for-the-regulation-of-electroniccigarettes.aspx#.Vz3oUfkrLrc>; accessed: October 22, 

2015.

American Association for Respiratory Care. Electronic 

cigarette [position statement], 2015; <https://www.

aarc.org/resources/professional-documents/positionstatements/>; accessed: October 22, 2015.

American Cancer Society. What about electronic 

cigarettes? Aren’t they safe?, 2014; <http://www.

cancer.org/cancer/cancercauses/tobaccocancer/

questionsaboutsmokingtobaccoandhealth/questionsabout-smoking-tobacco-and-health-e-cigarettes>;

accessed: October 22, 2015.

American College of Chest Physicians. World’s leading lung 

societies release position statement on e-cigarettes, 2014; 

<http://www.chestnet.org/News/Press-Releases/2014/07/

Worlds-Leading-Lung-Societies-Release-PositionStatement-on-ECigarettes>; accessed: October 22, 2015.

American Lung Association. E-cigarettes, 2014; <http://

www.lung.org/associations/charters/midland-states/

assets/pdfs/advocacy-pdfs/position-statement-on.pdf>;

accessed: October 22, 2015.

American Lung Association. American Lung Association 

statement on e-cigarettes, 2015; <http://www.

lung.org/stop-smoking/tobacco-control-advocacy/

federal/e-cigarettes.html>; accessed: September 14, 2015.

American Thoracic Society. [ATS policy position: 

E-cigarettes]. New York: American Thoracic Society, 2013; 

<http://www.thoracic.org/advocacy/press-releases/ATS_

Policy_Position_eCigarettes.pdf>; accessed: October 22,

2015.

American Thoracic Society. As use of e-cigarettes by children increases, the American Thoracic Society calls 

for tighter regulation, 2015; <http://www.thoracic.org/

about/newsroom/press-releases/journal/as-use-of-e-cigarettes-by-children-iIncreases-the-ats-calls-for-tighterregulation%20.php>; accessed: October 22, 2015.

Americans for Nonsmokers’ Rights Foundation. Going 

smoke free: North Dakota, n.d.; <http://no-smoke.org/

goingsmokefree.php?id=157>; accessed: May 14, 2015.

Americans for Nonsmokers’ Rights Foundation. U.S. 

State and Local Laws Regulating Use of Electronic 

Cigarettes. Oakland (CA): Americans for Nonsmokers’ 

Rights Foundation, 2015.

Americans for Nonsmokers’ Rights. Electronic cigarettes, 

n.d.a; <http://www.no-smoke.org/pdf/ecigarettes-4-pager.

pdf>; accessed: October 22, 2015.

Americans for Nonsmokers’ Rights. Electronic cigarettes 

are not a safe alternative, n.d.b; <http://www.no-smoke.

org/learnmore.php?id=645>; accessed: October 22, 

2015.

Association of State and Territorial Health Officials. Tobacco 

Use Prevention and Control Position Statement, 

September, 2014; <http://www.astho.org/Policy-andPosition-Statements/Position-Statement-on-Tobacco-UsePrevention-and-Control/>; accessed: November 12, 2015.

Bader P, Boisclair D, Ferrence R. Effects of tobacco taxation and pricing on smoking behavior in high risk 

populations: a knowledge synthesis. International 

Journal of Environmental Research and Public Health 

2011;8(11):4118–39.

Ballotpedia. North Dakota Smoking Ban Initiative, Measure 4, 

2012; <http://ballotpedia.org/North_Dakota_Smoking_

Ban_Initiative,_Measure_4_(2012)>; accessed: May 14, 

2015.

Bam TS, Bellew W, Berezhnova I, Jackson-Morris A, Jones 

A, Latif E, Molinari MA, Quan G, Singh RJ, Wisotzky M, 

et al. Position statement on electronic cigarettes or electronic nicotine delivery systems. International Journal 

of Tuberculosis and Lung Disease 2014;18(1):5–7.

Barrington-Trimis JL, Samet JM, McConnell R. Flavorings 

in electronic cigarettes: an unrecognized respiratory 
A Report of the Surgeon General

228 Chapter 5

health hazard? JAMA: the Journal of the American 

Medical Association 2014;312(23):2493–4.

Bates C. WHO position on ENDS (e-cigarettes): a 

critique of the use of science and communication of 

risk. Paper prepared for the Sixth Conference of the 

Parties (COP-6) of the Framework Convention on 

Tobacco Control (FCTC); October, 2014; Moscow; 

<https://nicotinepolicy.net/documents/briefings/

WHOpapercritique.pdf>; accessed: October 22, 2015.

Bauld L, MacKintosh AM, Ford A, McNeill A. E-cigarette 

uptake amongst UK youth: experimentation, but little 

or no regular use in nonsmokers. Nicotine & Tobacco 

Research 2016;18(1):102–3.

Benowitz NL. Emerging nicotine delivery products. 

Implications for public health. Annals of the American 

Thoracic Society 2014;11(2):231–5.

Bhatnagar A, Whitsel LP, Ribisl KM, Bullen C, Chaloupka 

F, Piano MR, Robertson RM, McAuley T, Goff D, 

Benowitz N. Electronic cigarettes: a policy statement 

from the American Heart Association. Circulation

2014;130(16):1418–36.

Bialous SA, Sarma L. Electronic cigarettes and smoking 

cessation: a quandary? Lancet 2014;383(9915):407–8.

Boonn A. The Best Way to Tax Smokeless Tobacco: A 

Simple Weight-Based Tax Hurts State Revenues and 

Increases Youth Use, August 1, 2013; <https://www.

tobaccofreekids.org/research/factsheets/pdf/0282.pdf>;

accessed: October 20, 2015.

Brandon TH, Goniewicz ML, Hanna NH, Hatsukami 

DK, Herbst RS, Hobin JA, Ostroff JS, Shields PG, 

Toll BA, Tyne CA, et al. Electronic nicotine delivery 

systems: a policy statement from the American 

Association for Cancer Research and the American 

Society of Clinical Oncology. Clinical Cancer Research

2015a;21(3):514–25.

Brandon TH, Goniewicz ML, Hanna NH, Hatsukami DK, 

Herbst RS, Hobin JA, Ostroff JS, Shields PG, Toll BA, 

Tyne CA, et al. Electronic nicotine delivery systems: 

a policy statement from the American Association 

for Cancer Research and the American Society of 

Clinical Oncology. Journal of Clinical Oncology

2015b;33(8):952–63.

BreatheND. Violations of North Dakota’s Smoke-Free Law. 

2014.

BreatheND. A Guide to North Dakota’s Smoke-Free Law, n.d.a.; 

<http://www.breathend.com/uploads/0/smokefreebro.pdf>;

accessed: February 19, 2016.

BreatheND. Smoke free law (home page), n.d.b.; <http://

www.breathend.com/smokefree/>; accessed: May 4, 

2016.

Britton J, Bogdanovica I. Electronic cigarettes: A report 

commissioned by Public Health England, 2014; 

<https://www.gov.uk/government/uploads/system/

uploads/attachment_data/file/311887/Ecigarettes_

report.pdf>; accessed: May 6, 2015.

Bunnell RE, Agaku IT, Arrazola RA, Apelberg BJ, Caraballo 

RS, Corey CG, Coleman BN, Dube SR, King BA. 

Intentions to smoke cigarettes among never-smoking 

U.S. middle and high school electronic cigarette users: 

National Youth Tobacco Survey, 2011–2013. Nicotine & 

Tobacco Research 2015;17(2):228–35.

Bureau of Prisons. Electronic Cigarettes (Operations 

memorandum 006-2015), 2015; <https://www.bop.gov/

policy/om/006_2015.pdf>; accessed: October 20, 2016.

Calantzopoulos A. PMI Annual Meeting of Shareholders, 

May 6, 2015; <http://www.businesswire.com/news/

home/20150506005550/en/Philip-Morris-InternationalPMI-Holds-2015-Annual>; accessed: September 15, 2015.

CAMQUIT. Electronic cigarettes—a summary of evidence 

and expert opinion, n.d.; <http://www.camquit.nhs.

uk/uploads/Electronic%20cigarettes.docx>; accessed: 

October 22, 2015.

Center for Public Health and Tobacco Policy. E-Cigarettes Fact 

Sheet. Revised October 2013. Boston (MA): New England 

Law Boston, 2013; <http://www.tobaccopolicycenter.

org/documents/CPHTP%20e-cig%20fact%20sheet%20

10-17-2013%20(2).pdf>; accessed: December 24, 2016.

Centers for Disease Control and Prevention. Tobacco 

Control State Highlights 2012. Atlanta (GA): U.S. 

Department of Health and Human Services, Centers 

for Disease Control and Prevention, National Center 

for Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health, 2013:300.

Centers for Disease Control and Prevention. State laws 

prohibiting sales to minors and indoor use of electronic nicotine delivery systems—United States, 

November 2014. Morbidity and Mortality Weekly 

Report 2014;63(49):1145–50.

Centers for Disease Control and Prevention. STATE System 

E-Cigarette Fact Sheet, 2015a; <https://chronicdata.

cdc.gov/Legislation/STATE-System-E-Cigarette-FactSheet/qte6-7jwd>; accessed: February 17, 2016.

Centers for Disease Control and Prevention. Tobacco 

use among middle and high school students—United 

States, 2011–2014. Morbidity and Mortality Weekly 

Report 2015b;64(14):381–5.

Centers for Disease Control and Prevention. Tobacco 

use among middle and high school students—United 

States, 2011–2015. Morbidity and Mortality Weekly 

Report 2016;65(14):361–7.

Centers for Medicare & Medicaid Services. National coverage determination (NCD) for counseling to prevent tobacco use (210.4.1), 2010; <https://www.cms.

gov/medicare-coverage-database/details/ncd-details.

aspx?NCDId=342>; accessed: September 28, 2015.
E-Cigarette Policy and Practice Implications 229

E-Cigarette Use Among Youth and Young Adults

Chaloupka FJ, Sweanor D, Warner KE. Differential taxes 

for differential risks—toward reduced harm from 

nicotine-yielding products. New England Journal of 

Medicine 2015;373(7):594–7.

Chang H. Research gaps related to the environmental 

impacts of electronic cigarettes. Tobacco Control

2014;23(Suppl 2):ii54–ii58.

ChangeLab Solutions. Licensing & Zoning: Tools for Public 

Health. Oakland (CA): ChangeLab Solutions, 2012; 

<http://www.changelabsolutions.org/sites/default/files/

Licensing&Zoning_FINAL_20120703.pdf>; accessed: 

October 20, 2015.

ChangeLab Solutions. Local Strategies to Regulate Vape 

Shops & Lounges Law & Policy Innovation for the 

Common Good. Oakland (CA): ChangeLab Solutions, 

2014; <http://www.changelabsolutions.org/sites/default/

files/Vapor_Lounges_FINAL_20140926_1.pdf>; accessed: 

September 16, 2015.

ChangeLab Solutions. Model California Ordinance 

Regulating Electronic Smoking Devices (with 

Annotations). Sacramento (CA): California Department 

of Public Health, 2015a.

ChangeLab Solutions. What is a “moratorium ordinance,” 

and how can it affect tobacco sales in your community?, 2015b; <http://www.changelabsolutions.org/faqmoratorium-ordinance>; accessed: April 27, 2015.

Choi K, Forster JL. Beliefs and experimentation with electronic cigarettes: a prospective analysis among young 

adults. American Journal of Preventive Medicine

2014;46(2):175–8.

City of Hayward. City of Hayward council agenda: June 

24, 2014, 2014; <http://www.hayward-ca.gov/CITYGOVERNMENT/CITY-COUNCIL-MEETINGS/2014/

CCA14PDF/cca062414full.pdf>; accessed: October 20, 

2015.

City of Hayward. City of Hayward Tobacco Retail License 

Program: Frequently Asked Questions, n.d.a; <http://www.

hayward-ca.gov/CITY-GOVERNMENT/DEPARTMENTS/

CITY-MANAGER/documents/2015/TRL_FAQ.pdf>;

accessed: October 20, 2015.

City of Hayward. Tobacco retail inspection, n.d.b; <http://

user.govoutreach.com/hayward/faq.php?cid=28719>;

accessed: October 20, 2015.

Cobb CO, Villanti AC, Graham AL, Pearson JL, Glasser AM, 

Rath JM, Stanton CA, Levy DT, Abrams DB, Niaura R. 

Markov modeling to estimate the population impact of 

emerging tobacco products: a proof-of-concept study. 

Tobacco Regulatory Science 2015;1(2):129–41.

Cobb NK, Abrams DB. The FDA, e-cigarettes, and the 

demise of combusted tobacco. New England Journal of 

Medicine 2014;371(16):1469–71.

Committees of Advertising Practice. New UK advertising 

rules for e-cigarettes, 2014; <http://www.cap.org.uk/

News-reports/Media-Centre/2014/New-ecig-ad-rules.

aspx#.VVZa9mCeeFJ>; accessed: August 18, 2015.

Community Preventive Services Task Force. Community 

mobilization with additional interventions to 

restrict minors’ access to tobacco products, 2001; 

<http://www.thecommunityguide.org/tobacco/

RRcommunityinterventions.html>; accessed: April 19, 2015.

Community Preventive Services Task Force. Reducing 

tobacco use and secondhand smoke exposure: interventions to increase the unit price for tobacco products, 

2012; <http://www.thecommunityguide.org/tobacco/

increasingunitprice.html>; accessed: April 15, 2015.

Crowley RA, Health Public Policy Committee of the 

American College of Physicians. Electronic nicotine 

delivery systems: executive summary of a policy position paper from the American College of Physicians. 

Annals of Internal Medicine 2015;162(8):583–4.

England LJ, Bunnell RE, Pechacek TF, Tong VT, McAfee 

TA. Nicotine and the developing human: a neglected 

element in the electronic cigarette debate. American 

Journal of Preventive Medicine 2015;49(2):286–93.

European Parliament and Council. Directive 2014/40/

EU of the European Parliament and of the Council of 

3 April 2014 on the approximation of the laws, regulations and administrative provisions of the member 

states concerning the manufacture, presentation and 

sale of tobacco and related products and repealing 

Directive 2001/37/EC text with EEA relevance. Official 

Journal of the European Union 2014;57:1–38.

European Respiratory Society. ERS position on the 

Revision of the Tobacco Products Directive, 2014; 

<http://www.ersnet.org/ers-position-on-the-revisionof-the-tobacco-products-directive.html>; accessed: 

October 22, 2015.

Executive Office of the President. Federal Leadership on 

Global Tobacco Control and Prevention, 2001, January 23; 

<https://www.federalregister.gov/d/01-2139>; accessed: 

October 20, 2016.

Executive Office of the President. Protecting federal 

employees and the public from exposure to tobacco 

smoke in the federal workplace, 1997, August 13; 

<https://www.federalregister.gov/d/97-21607>; 

accessed: October 20, 2016.

Fagerström KO, Bridgman K. Tobacco harm reduction: 

the need for new products that can compete with cigarettes. Addictive Behaviors 2014;39(3):507–11.

Family Smoking Prevention and Tobacco Control Act. 

Public Law 111-31, 123 U.S. Statutes at Large 1776 

(2009).

Farsalinos KE, Polosa R. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. Therapeutic Advances in 

Drug Safety 2014;5(2):67–86.
A Report of the Surgeon General

230 Chapter 5

Federal Register. U.S. Department of Veterans Affairs, 

Elimination of copayment for smoking cessation counseling. 71 Fed. Reg. 2464 (2006).

Federal Register. U.S. Department of Labor, Occupational 

Safety and Health Administration (OSHA), Indoor air 

quality. 66 Fed. Reg. 64946 (2001).

Federal Register. Advertisements which appear in news 

format. In: Title 16–Commercial Practices (21 CFR 

0.735-1, § 15.191), 1972:154.

Federal Register. Appendix A to subpart A of subpart A of 

part 3020—mail classification schedule—continued, 

part 102–74—facility management, General Services 

Administration. What is the smoking policy for interior 

space in Federal facilities? 78 Fed. Reg. 77518 (2008); 

<http://www.gpo.gov/fdsys/pkg/FR-2008-12-19/pdf/

E8-30180.pdf#page=2>; accessed: December 23, 2015.

Federal Register. U.S. Department of Housing and Urban 

Development. Request for information on adopting 

smoke-free policies in PHAs and multifamily housing: 

a notice by the Housing and Urban Development 

Department on 10/04/2012. 77 Fed. Reg. 60712 (2012); 

<https://federalregister.gov/a/2012-24430>; accessed: 

November 18, 2015.

Federal Register. U.S. Department of Housing and Urban 

Development. Instituting smoke-free public housing: a 

proposed rule by the Housing and Urban Development 

Department on 11/17/2015. 80 Fed. Reg. 71762 (2015); 

<https://federalregister.gov/a/2015-29346>; accessed: 

November 17, 2015.

Federal Register. U.S. Department of Health and Human 

Services, Food and Drug Administration. Deeming 

Tobacco Products To Be Subject to the Federal Food, Drug, 

and Cosmetic Act, as Amended by the Family Smoking 

Prevention and Tobacco Control Act; Restrictions on the 

Sale and Distribution of Tobacco Products and Required 

Warning Statements for Tobacco Products. 81 Fed. Reg.

28974 (2016); <https://federalregister.gov/a/2016-10685>;

accessed: May 16, 2016.

Federal Trade Commission. Complaint 103 in the matter 

of Cliffdale Associates, Inc. et al. In: Federal Trade 

Commission Decisions. 1984:110–22; <https://www.

ftc.gov/sites/default/files/documents/commission_

decision_volumes/volume-103/ftc_volume_

decision_103_january_-_june_1984pages_103-203.

pdf>; accessed: October 20, 2015.

Federal Trade Commission. FTC policy statement regarding 

advertising substantiation, 1983, March 11; <https://

www.ftc.gov/public-statements/1983/03/ftc-policystatement-regarding-advertising-substantiation>; 

accessed: October 20, 2016.

Feighery EC, Ribisl KM, Schleicher N, Lee RE, Halvorson 

S. Cigarette advertising and promotional strategies in

retail outlets: results of a statewide survey in California. 

Tobacco Control 2001;10(2):184–8.

Fiore MC, Schroeder SA, Baker TB. Smoke, the chief 

killer—strategies for targeting combustible tobacco use. 

New England Journal of Medicine 2014;370(4):297–9.

Flouris AD, Chorti MS, Poulianiti KP, Jamurtas AZ, Kostikas 

K, Tzatzarakis MN, Wallace Hayes A, Tsatsakis AM, 

Koutedakis Y. Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung 

function. Inhalation Toxicology 2013;25(2):91–101.

Freiberg M. Options for state and local governments to 

regulate non-cigarette tobacco products. Annals of 

Health Law 2012;21(2):407–45, 5 p preceding i.

Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak 

A, Kurek J, Prokopowicz A, Jablonska-Czapla M, RosikDulewska C, Havel C, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco Control 2014;23(2):133–9.

Goniewicz ML, Lee L. Electronic cigarettes are a source 

of thirdhand exposure to nicotine. Nicotine & Tobacco 

Research 2015;17(2):256–8.

Grana RA, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circulation 2014a;129(19):1972–86.

Grana RA, Ling PM, Benowitz N, Glantz S. Electronic 

cigarettes. Cardiology patient page. Circulation

2014b;129(19):e490–e492.

Hagopian A, Halperin A, P. A, Fradkin N, Gilroy JH, 

Medeiros E. E-Cigarettes: Evidence and Policy Options 

for Washington State. Seattle (WA): University of 

Washington, School of Public Health, Department of 

Health Services, January 2015; <http://www.governor.

wa.gov/sites/default/files/documents/ECigWhitePaper.

PDF>; accessed: October 20, 2015.

Hajek P, Etter JF, Benowitz N, Eissenberg T, McRobbie H. 

Electronic cigarettes: review of use, content, safety, 

effects on smokers and potential for harm and benefit. 

Addiction 2014;109(11):1801–10.

Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead 

LF, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews 2016, 

Issue 9. Art. No.: CD010216. DOI: 10.1002/14651858.

CD010216.pub3

Henningfield JE. The tobacco endgame: it’s all about 

behavior. Preventive Medicine 2014;68:11–6.

Hill AB. The environment and disease: association or causation? Proceedings of the Royal Society of Medicine

1965;58:295–300.

Hopkins DP, Razi S, Leeks KD, Priya Kalra G, Chattopadhyay 

SK, Soler RE. Smokefree policies to reduce tobacco use. 

A systematic review. American Journal of Preventive 

Medicine 2010;38(2 Suppl):S275–S289.

Huang J, Tauras J, Chaloupka FJ. The impact of price 

and tobacco control policies on the demand for 
E-Cigarette Policy and Practice Implications 231

E-Cigarette Use Among Youth and Young Adults

electronic nicotine delivery systems. Tobacco Control

2014;23(Suppl 3):iii41–iii47.

Immigration and Naturalization Service. INS Detention 

Standard Detainee Handbook, 2000; <http://www.ice.

gov/doclib/dro/detention-standards/pdf/handbk.pdf>; 

accessed: October 20, 2016.

Ingebrethsen BJ, Cole SK, Alderman SL. Electronic cigarette aerosol particle size distribution measurements. 

Inhalation Toxicology 2012;24(14):976–84.

Institute for Global Tobacco Control. Country laws regulation e-cigarettes: a policy scan, n.d. <http://globaltobaccocontrol.org/e-cigarette/country-laws/view>; 

accessed: October 4, 2016.

International Union Against Tuberculosis and Lung Cancer. 

Position statement on electronic cigarettes (ECs) or 

electronic nicotine delivery systems (ENDS), 2013; 

<http://www.theunion.org/what-we-do/publications/

official/body/E-cigarette_statement_FULL.pdf>;

accessed: October 22, 2015.

Kalkhoran S, Glantz SA. Modeling the health effects of 

expanding e-cigarette sales in the United States and 

United Kingdom: a Monte Carlo analysis. JAMA Internal 

Medicine 2015;175(10):1671–80.

Klein JD. Electronic cigarettes are another route 

to nicotine addiction for youth. JAMA Pediatrics 

2015;169(11):993–4.

Krause MJ, Townsend TG. Hazardous waste status of 

discarded electronic cigarettes. Waste Management

2015;39:57–62.

Kreiss K, Gomaa A, Kullman G, Fedan K, Simoes EJ, 

Enright PL. Clinical bronchiolitis obliterans in workers 

at a microwave-popcorn plant. New England Journal of 

Medicine 2002;347(5):330–8.

Laird-Metke EP. Regulating Tobacco Marketing: 

“Commercial Speech” Guidelines for State and Local 

Governments. Saint Paul (MN): Tobacco Control Legal 

Consortium, 2010; <http://publichealthlawcenter.org/

sites/default/files/resources/tclc-guidelines-speech-2010.

pdf>; accessed: October 20, 2015.

Leventhal AM, Strong DR, Kirkpatrick MG, Unger JB, 

Sussman S, Riggs NR, Stone MD, Khoddam R, Samet 

JM, Audrain-McGovern J. Association of electronic cigarette use with initiation of combustible tobacco product 

smoking in early adolescence. JAMA: the Journal of the 

American Medical Association 2015;314(7):700–7.

Levy DT, Cummings KM, Villanti AC, Niaura R, Abrams 

DB, Fong GT, Borland R. A framework for evaluating 

the public health impact of e-cigarettes and other 

vaporized nicotine products. Addiction 2016.

Lindblom EN. Effectively regulating e-cigarettes and their 

advertising—and the First Amendment. Food and 

Drug Law Journal 2015;70(1):55–92.

Mark KS, Farquhar B, Chisolm MS, Coleman-Cowger VH, 

Terplan M. Knowledge, attitudes, and practice of electronic cigarette use among pregnant women. Journal 

of Addiction Medicine 2015;9(4):266–72.

McLaughlin I. License to Kill?: Tobacco Retailer Licensing 

as an Effective Enforcement Tool. Saint Paul (MN): 

Tobacco Control Legal Consortium, 2010; <http://

publichealthlawcenter.org/sites/default/files/resources/

tclc-syn-retailer-2010.pdf>; accessed: October 20, 2015.

McMillen RC, Gottlieb MA, Winickoff JP. E-cigarettes—

the roles of regulation and clinicians. JAMA Internal 

Medicine 2015;175(10):1603–4.

McNeill A, Brose LS, Calder R, Hitchman SC, Hajek P, 

McRobbie H. E-Cigarettes: An Evidence Update—A 

Report Commissioned by Public Health England. 

London (UK): Public Health England, 2015.

Mejia AB, Ling PM, Glantz SA. Quantifying the effects of promoting smokeless tobacco as a harm reduction strategy 

in the USA. Tobacco Control 2010;19(4):297–305.

Minnesota Revenue. E-Cigarettes Are Taxable in 

Minnesota, 2014; <http://www.revenue.state.mn.us/

businesses/tobacco/Documents/ecigarette_flyer.pdf>;

accessed: April 25, 2015.

National Association of County and City Health Officials. 

Statement of Policy: Regulation of Electronic Cigarettes 

(“E-Cigarettes”). Washington (DC): National Association 

of County and City Health Officials, April 2014; <http://

www.naccho.org/advocacy/positions/upload/12-04-eCigarettes.pdf>; accessed: October 20, 2015.

National Cancer Institute. The Role of the Media in 

Promoting and Reducing Tobacco Use. Smoking and 

Tobacco Control Monograph No. 19. Bethesda (MD): 

U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute, 

2008. NIH Publication No. 07-6242.

National Conference of State Legislatures. Alternative 

nicotine products/electronic cigarettes, 2015; <http://

www.ncsl.org/research/health/alternative-nicotineproducts-e-cigarettes.aspx>; accessed: September 16, 

2015.

National Institute on Drug Abuse. Points to consider 

regarding tobacco industry funding of NIDA applicants, 

2016, March; <https://www.drugabuse.gov/about-nida/

advisory-boards-groups/national-advisory-councildrug-abuse-nacda/council-statements/points-to-consider-regarding-tobacco-industry-funding-nida>; 

accessed: October 20, 2016.

National Institutes of Health. Taking our own best advice: 

a tobacco-free NIH [website]; 2016, June 8; <http://

tobaccofree.nih.gov/>; accessed: October 20, 2016.

Offermann F. The hazards of e-cigarettes. ASHRAE Journal. 

2014 June:38–44.
A Report of the Surgeon General

232 Chapter 5

Partnership for Prevention. Position Statement on 

E-Cigarettes, 2014; <http://www.prevent.org/data/files/

actiontoquit/e-cigarette%20position%20statement%20

may%202014.pdf>; accessed: October 20, 2015.

Pisinger C, Dossing M. A systematic review of health 

effects of electronic cigarettes. Preventive Medicine

2014;69:248–60.

Pokhrel P, Fagan P, Kehl L, Herzog TA. Receptivity 

to e-cigarette marketing, harm perceptions, and 

e-cigarette use. American Journal of Health Behavior

2015;39(1):121–31.

Primack BA, Soneji S, Stoolmiller M, Fine MJ, Sargent JD. 

Progression to traditional cigarette smoking after electronic cigarette use among U.S. adolescents and young 

adults. JAMA Pediatrics 2015:1–7.

Pucci LG, Joseph HM, Jr., Siegel M. Outdoor tobacco advertising in six Boston neighborhoods. Evaluating youth 

exposure. American Journal of Preventive Medicine

1998;15(2):155–9.

Richardson A, Ganz O, Stalgaitis C, Abrams D, Vallone 

D. Noncombustible tobacco product advertising: how 

companies are selling the new face of tobacco. Nicotine 

& Tobacco Research 2014;16(5):606–14.

Rigotti NA, Moran SE, Wechsler H. U.S. college students’ 

exposure to tobacco promotions: prevalence and association with tobacco use. American Journal of Public 

Health 2005;95(1):138–44.

Roeseler A, Feighery EC, Cruz TB. Tobacco marketing 

in California and implications for the future. Tobacco 

Control 2010;19(Suppl 1):i21–9.

Rose SW, Barker DC, D’Angelo H, Khan T, Huang J, 

Chaloupka FJ, Ribisl KM. The availability of electronic cigarettes in U.S. retail outlets, 2012: results of 

two national studies. Tobacco Control 2014;23(Suppl 

3):iii10–iii16.

Saitta D, Ferro GA, Polosa R. Achieving appropriate regulations for electronic cigarettes. Therapeutic Advances 

in Chronic Disease 2014;5(2):50–61.

Schober W, Szendrei K, Matzen W, Osiander-Fuchs H, 

Heitmann D, Schettgen T, Jorres RA, Fromme H. Use 

of electronic cigarettes (e-cigarettes) impairs indoor 

air quality and increases FeNO levels of e-cigarette 

consumers. International Journal of Hygiene and 

Environmental Health 2014;217(6):628–37.

Schraufnagel DE, Blasi F, Drummond MB, Lam DC, 

Latif E, Rosen MJ, Sansores R, Van Zyl-Smit R. 

Electronic cigarettes. A position statement of the 

forum of international respiratory societies. American 

Journal of Respiratory and Critical Care Medicine

2014;190(6):611–8.

Schripp T, Markewitz D, Uhde E, Salthammer T. Does 

e-cigarette consumption cause passive vaping? Indoor 

Air 2013;23(1):25–31.

Shang C, Chaloupka FJ, Fong GT, Thompson M, O’Connor 

RJ. The association between tax structure and cigarette price variability: findings from the ITC Project. 

Tobacco Control 2015;24(Suppl 3):iii88–iii93.

Siegel MB, Tanwar KL, Wood KS. Electronic cigarettes 

as a smoking-cessation: tool results from an online 

survey. American Journal of Preventive Medicine

2011;40(4):472–5.

Sleiman M, Logue JM, Montesinos VN, Russell ML, Litter 

MI, Gundel LA, Destaillats H. Emissions from electronic cigarettes: key parameters affecting the release 

of harmful chemicals. Environmental Science & 

Technology 2016;50(17):9644–51.

Sottera, Inc. v. Food and Drug Administration, No. 627 

F.3d 891 (D.C. Cir. 2010).

Sussman S, Garcia R, Cruz TB, Baezconde-Garbanati L, 

Pentz MA, Unger JB. Consumers’ perceptions of vape 

shops in Southern California: an analysis of online Yelp 

reviews. Tobacco Induced Diseases 2014;12(1):22.

The Center for Tobacco Policy & Organizing. Local Policies 

on the Use of Electronic Cigarettes. Sacramento 

(CA): The American Lung Association in California, 

2015a; <http://center4tobaccopolicy.org/wp-content/

uploads/2015/04/Local-Policies-on-Use-of-E-CigsApril-20151.pdf>; accessed: October 20, 2015.

The Center for Tobacco Policy & Organizing. Reducing Youth 

Access to Electronic Cigarettes through Tobacco Retailer 

Licensing. Sacramento (CA): The American Lung Association 

in California, 2015b; <http://center4tobaccopolicy.

org/wp-content/uploads/2014/05/E-cigarettes-in-TRLApril-2015.pdf>; accessed: October 20, 2015.

The Council of State Governments. Health Policy: 

E-Cigarettes: Regulation and Taxation. 2015; <http://

knowledgecenter.csg.org/kc/system/files/CR_e_

Cigarettes.pdf>; accessed: October 20, 2015.

Tobacco Control Legal Consortium. E-Cigarette Taxation: 

Frequently Asked Questions. St. Paul (MN): Public 

Health Law Center at William Mitchell College of Law, 

March 2015; <http://publichealthlawcenter.org/sites/

default/files/resources/tclc-fs-ecig-taxation-2015.pdf>;

accessed: October 20, 2015.

United Nations Educational, Scientific and Cultural 

Organization. The Precautionary Principle. World 

Commission on the Ethics of Scientific Knowledge and 

Technology. Paris (France): UNESCO, 2005; <http://

unesdoc.unesco.org/images/0013/001395/139578e.

pdf>; accessed: August 23, 2016.

U.S. Air Force. Air Force Instruction 40-102, Tobacco 

Use in the Air Force, 2013; <http://static.e-publishing.af.mil/production/1/501csw/publication/

afi40-102_501cswsup/afi40-102_501cswsup_i.pdf>;

accessed: September 28, 2015.
E-Cigarette Policy and Practice Implications 233

E-Cigarette Use Among Youth and Young Adults

U.S. Army. Army Health Promotion, 1996; <http://

ndri.org/docs/Army%20Regulation%20600-63%20

Army%20Health%20Promotion%2028%20May%20

1996.rtf>; accessed: September 28, 2015.

U.S. Department of Defense. Armed Services Exchange 

Policy. DoD Directive 1330.09 (December 7), 2005; 

<http://www.dtic.mil/whs/directives/corres/pdf/133009p.

pdf>; accessed: May 2, 2013.

U.S. Department of Health and Human Services. Preventing 

Tobacco Use Among Youth and Young Adults: A Report 

of the Surgeon General. Atlanta (GA): U.S. Department 

of Health and Human Services, Centers for Disease 

Control and Prevention, National Center for Chronic 

Disease Prevention and Health Promotion, Office on 

Smoking and Health, 2012.

U.S. Department of Health and Human Services. 

Smoking—50 Years of Progress: A Report of the 

Surgeon General. Atlanta (GA): U.S. Department 

of Health and Human Services, Centers for Disease 

Control and Prevention, National Center for Chronic 

Disease Prevention and Health Promotion, Office on 

Smoking and Health, 2014.

U.S. Department of Health and Human Services. Current 

Intelligence Bulletin 67: Promoting Health and 

Preventing Disease and Injury through Workplace 

Tobacco Policies. U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention, National 

Institute for Occupational Safety and Health, 2015.

U.S. Food and Drug Administration, Center for Tobacco 

Products. A strategic partnership, n.d.; <http://www.

fda.gov/downloads/TobaccoProducts/NewsEvents/

UCM284343.pdf>; accessed: September 12, 2016.

U.S. General Services Administration. 5800.1C ADM 

smoking in GSA-occupied space and government-owned 

or -leased vehicles assigned to GSA, 2009; <http://www.

gsa.gov/portal/directive/d0/content/520618>; accessed: 

September 28, 2015.

U.S. Navy. Naval Hospital Twentynine Palms Instruction 

5100.13e (October 7), 2002; <http://ndri.org/docs/

US%20Naval%20Hospital%2029%20Palms%20

Instruction%205100.13E%20Tobacco%20Use%20.

pdf>; accessed: September 28, 2015.

Vugrin ED, Rostron BL, Verzi SJ, Brodsky NS, Brown TJ, 

Choiniere CJ, Coleman BN, Paredes A, Apelberg BJ. 

Modeling the potential effects of new tobacco products 

and policies: a dynamic population model for multiple 

product use and harm. PloS One 2015;10(3):e0121008.

West R, Brown J. Electronic cigarettes: fact and faction. 

British Journal of General Practice 2014;64(626):442–3.

Whitsel LP, Benowitz N, Bhatnagar A, Bullen C, Goldstein 

F, Matthias-Gray L, Grossmeier J, Harris J, Isaac F, 

Loeppke R, et al. Guidance to employers on integrating 

e-cigarettes/electronic nicotine delivery systems into 

tobacco worksite policy. Journal of Occupational and 

Environmental Medicine 2015;57(3):334–43.

WHO Framework Convention on Tobacco Control. 

European Union: Revised EU Tobacco Products 

Directive approved by the European Parliament, 2014; 

<http://www.who.int/fctc/implementation/news/news_

eu_14/en/>; accessed: October 22, 2015.

Wills TA, Knight R, Sargent JD, Gibbons FX, Pagano I, 

Williams RJ. Longitudinal study of e-cigarette use and 

onset of cigarette smoking among high school students 

in Hawaii. Tobacco Control 2016.

World Health Organization. Decision: Electronic Nicotine 

Delivery Systems and Electronic Non-Nicotine Delivery 

Systems. Moscow (Russian Federation): Conference on 

the Parties to the WHO Framework. 2014a:2.

World Health Organization. Electronic Nicotine Delivery 

Systems 2014b <http://apps.who.int/gb/fctc/PDF/cop6/

FCTC_COP6_10Rev1-en.pdf?ua=1>; accessed: October 

22, 2015.